Mobile Medicine Communication Platform and Methods and Uses Thereof

ABSTRACT

Telemedicine systems and methods are described. In a telemedicine system operable to communicate with a remote operations center, communications can be transmitted/received using a transceiver having an antenna. The antenna can include first and second di-pole antenna elements, the first di-pole antenna element being vertically polarized and the second di-pole antenna element being horizontally polarized. A controller of the system can establish, using the transceiver, a telemedicine session with the operations center using a Transport Morphing Protocol (TMP), the TMP being an acknowledgement-based user datagram protocol. The controller can also mask one or more transient network degradations to increase resiliency of the telemedicine session. The telemedicine system can include a 2D and 3D carotid Doppler and transcranial Doppler and/or other diagnostic devices, and provides for real-time connectivity and communication between medical personnel in an emergency vehicle and a receiving hospital for immediate diagnosis and treatment to a patient in need.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation based on U.S. Ser. No. 15/487,955,filed Apr. 14, 2017, which claims priority to and the benefit of U.S.Provisional Application No. 62/323,005, filed on Apr. 15, 2016, whichare each hereby incorporated by reference.

This application also discloses products and references, such as (A) PCTApplication No. PCT/US2013/067713, which was filed on Oct. 31, 2013 andentitled “Novel System for Emboli Detection in the Brain Using aTranscranial Doppler Photoacoustic Device Capable of Vasculature andPerfusion Measurement;” (B) U.S. patent application Ser. No. 14/674,411,which was filed on Mar. 31, 2015 and entitled “Helmet Apparatus andSystem with Carotid Collar Means On-Boarded;” (C) U.S. patentapplication Ser. No. 14/070,264, filed on Nov. 1, 2013 and entitled“Emboli detection in the brain using a transcranial Dopplerphotoacoustic device capable of vasculature and perfusion measurement;”(D) U.S. patent application Ser. No. 14/084,039, which was filed on Nov.19, 2013 and entitled “Method and Device for Identification of OneCarbon Pathway Gene Variants as Stroke Risk Markers, Combined DataMining, Logistic Regression, and Pathway Analysis;” (E) U.S. ProvisionalApplication No. 61/720,992, which was filed on Oct. 31, 2012; (F) U.S.Provisional Application No. 61/794,618, which was filed on Jan. 7, 2013;and (G) U.S. Provisional Application No. 61/833,802, which was filed onJun. 11, 2013, and the disclosures of such products and references arehereby incorporated by reference.

TECHNICAL FIELD

Aspects described herein generally relate to devices and methods mobiletelemedicine, including mobile telemedicine devices and methods fortreating traumatic event in the brain, for example, a stroke,cerebrovascular accident (CVA), concussion or a seizure, as well astrauma in general and other acute medical disorders.

BACKGROUND AND RELATED ART

Strokes impact approximately 795,000 Americans each year. Of these, 30%may involve the large vessels, the middle cerebral arteries, the basilarartery, and the carotid arteries. Only 10% of these patients receivedefinitive early diagnosis and therapy A stroke occurs when a vessel inthe brain ruptures or is blocked by a blood clot. Although progress hasbeen made in reducing stroke mortality, it is the fourth leading causeof death in the United States. Moreover, stroke is the leading cause ofdisability in the United States and the rest of the world. In fact, 20%of survivors still require institutional care after 3 months and 15% to30% experience permanent disability. This life-changing event affectsthe patient's family members and caregivers. With an aging USpopulation, the situation will only become more desperate. Moresignificant disability may be associated with large vessel obstructionand large vessel strokes.

Individuals afflicted with a stroke must receive immediate medicalattention or risk suffering long term effects. However, many individualssuffering a stroke do not receive medical attention in time or are notdiagnosed with a stroke. In some instances, patients are rushed to theclosest hospital, but not the appropriate hospital equipped for treatinga stroke patient. A hospital may be inappropriate because of inadequatediagnostic equipment, or lack of immediate access to required diagnosticand imaging testing. Also, the hospital may lack medical professionals,such as neurologists or interventional vascular specialists who aretrained to give expert interpretation and necessary and warrantedtherapies. By the time the patient is diagnosed with a stroke, it may bediscovered that the patient is at the wrong hospital and the potentialfor long term affects increases. In a stroke, 2 million nerve cells dieper minute. Therefore, time is of the essence when diagnosing andtreating stroke patients. It is best to start treatment within an hourof stroke onset.

However, definitive stroke treatment using, for example, clot bustertherapy or brain or neck vessel clot removal or clot bypass can beinitiated with stroke reversal or reduction in severity and morbidityand elimination of mortality. A golden hour from stroke onset to therapyin selected strokes, particularly those involving the large vessels isrecommended, but blood thinner therapy up until 4.5 hours and clotremoval up until 6-8 hours but with diminished efficacy of the treatmentafter the first hour. Early diagnosis and therapy is particularlyimportant for stroke involving the large vessels of the brain and neck(i.e., large vessel obstructions) and only 10% of eligible patientsreceive definitive therapy. These strokes have the highest potential forsignificant morbidity and mortality. Adverse factors may affect strokecare. In some instances, definitive therapy may not be available becausethe stroke has already occurred or is too large and cannot be reversed.

Despite national protocols for stroke care with improved prognosis, theprocess and logistics of patient care from time of onset (T 1) of Strokeor traumatic brain injury (TBI) Episode through initial hospitalencounter and emergent and acute care during the acute episode (T ‘n’)in the Emergency Department is inconsistent nationwide. Otherinconsistencies with variability and incompleteness nationwide includethe capture, collection and communication of pertinent patient data,communication among the entire community of 1st responders and ERphysicians/radiologists and staff, and a neurological examination. Assuch, definitive diagnosis and treatment may not occur on initialpresentation at the emergency department. Disorders that are not strokemay not be identified, but still receive potentially dangerous therapyfor stroke. Thus, optimal, personalized care is not being done. Hence,there may be delivery of patients to inappropriate sites,unsafe/unwarranted treatment, delayed treatment, inability to treat dueto time limitations, increased brain damage, and poorer prognosis.

If the patient arrives late, or is seen outside of the acceptable timewindow, or the patient has too many other medical risk factors to allowdefinitive therapy, then these factors may lead to complications,including brain hemorrhage. Also, screening of patients with strokecausing conditions is often not done. This can lead to a stroke, whichmay be preventable. Traumatic brain injury occurs in 1.7M patients peryear, including but not limited to concussion and brain hemorrhage.These may be mild, moderate, or severe. In the context of traumaticbrain injury, vascular obstruction, narrowing due to vessel spasm, andvessel tearing of brain and neck vessels place this group of disordersin those needing evaluation as well as those needing attention to theirvascular efficacy. The system and methods of the exemplary embodimentsdescribed herein will be useful for identification and diagnosis andearly therapy for this group of disorders, as well as other braininjuries or other medical conditions.

SUMMARY

As an overview, the present disclosure provides a systems and methodsfor assessing a patient for one or more traumatic brain injuries, suchas for a stroke, and other neurological disorders while in transport inan emergency vehicle, such as an ambulance, emergency helicopter,airplane, train, boat and/or other vehicle. The disclosure is notlimited to in-transit assessments and can include assessing a patient ina diagnostic facility such as an urgent care facility, doctor's office,clinics, nursing homes, fire station, police station, or anotherfacility. The telemedicine system can also be a portable configurationthat can be brought into a facility by emergency personnel whenassessing a patent.

In consideration of the above problems, in accordance with one aspectdisclosed herein, a telemedicine system operable to communicate with aremote operations center, comprising a transceiver configured totransmit or receive one or more communications via an antenna havingfirst and second di-pole antenna elements, the first di-pole antennaelement being vertically polarized and the second di-pole antennaelement being horizontally polarized; and a controller connected to thetransceiver and configured to establish, using the transceiver, atelemedicine session with the operations center using a TransportMorphing Protocol (TMP), the TMP being an acknowledgement-based userdatagram protocol; and mask one or more transient network degradationsto increase resiliency of the telemedicine session.

In an exemplary embodiment, the controller is configured to (a) adjustdata send rate of the telemedicine session to reduce packet loss andreduce the resending of packets of the telemedicine session and (b)switch between cellular communication and satellite communication upondetecting a transient network loss.

In an exemplary embodiment, the controller is configured to encryptcommunications of the telemedicine session such that the telemedicinesession is a secure telemedicine session; the controller being connectedto a router, the router being connected to a cellular modem and twodifferent kinds of satellite modems.

In an exemplary embodiment, the two different kinds of satellite modemsinclude a first modem configured to transmit data over a Ku or Ka bandantenna and a second modem configured to transmit data over an L-Bandantenna.

In an exemplary embodiment, a vehicle comprising the telemedicinesystem, a plurality of wheels, and a motor configured to drive theplurality of wheels.

In an exemplary embodiment, the telemedicine system further comprises arouter connected to the transceiver, the router being configured toroute communications between the controller and the transceiver, andwherein the controller is configured to controller the router todynamically switch between the two or more wireless communicationprotocols.

In an exemplary embodiment, the telemedicine system further comprises asatellite transceiver configured to transmit or receive one or moresatellite communications to/from one or more orbiting satellites.

In an exemplary embodiment, the controller is configured to control thetelemedicine system to dynamically switch communications of thetelemedicine session between the transceiver and the satellitetransceiver.

In an exemplary embodiment, the telemedicine system further comprises arouter connected to the transceiver and the satellite transceiver,wherein the controller is configured to control the router todynamically switch the communications of the telemedicine sessionbetween the transceiver and the satellite transceiver.

In an exemplary embodiment, the first di-pole antenna element includesfirst and second vertically-arranged antenna radiators, the firstvertically-arranged antenna radiator being arranged orthogonal to thesecond vertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other.

In an exemplary embodiment, the second di-pole antenna element includesfirst and second horizontally-arranged antenna radiators, the first andthe second horizontally-arranged antenna radiators being arranged in asame horizontal plane.

In an exemplary embodiment, the first di-pole antenna element includesfirst and second vertically-arranged antenna radiators, the firstvertically-arranged antenna radiator being arranged orthogonal to thesecond vertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other; and the second di-pole antennaelement includes first and second horizontally-arranged antennaradiators, the first and the second horizontally-arranged antennaradiators being arranged in a same horizontal plane.

In an exemplary embodiment, the first and second di-pole antennaelements are enclosed in a single radome.

In an exemplary embodiment, the telemedicine system further comprisesone or more medical imaging modalities configured to generate one ormore medical images of a patient, wherein controller is configured totransmit the one or more medical images to the operations center usingthe transceiver; a satellite transceiver comprising a VSAT modemconnected to a flat panel phased array satellite terminal comprising atleast one antenna configured to communicate over Ku or Ka bands, anL-Band satellite modem connected to an L-band satellite antenna, and arouter connected to both the VSAT modem and the L-Band satellite modem;the controller being configured to monitor signal strength of the VSATmodem and the L-Band modem and to cause the router to dynamically switchbetween the modems based on the monitored signal strengths.

In accordance with another aspect disclosed herein, a telemedicinesystem operable to communicate with a remote operations center and oneor more medical facilities, comprising a transceiver configured totransmit or receive one or more communications using the two or morewireless communication protocols via an antenna having first and seconddi-pole antenna elements, the first di-pole antenna element beingvertically polarized and the second di-pole antenna element beinghorizontally polarized; a satellite transceiver configured to transmitor receive one or more satellite communications to/from one or moreorbiting satellites; a router connected to the transceiver and thesatellite transceiver, the router being configured to routecommunications to and from the transceiver and the satellite transceiverand to dynamically switch between the two or more wireless communicationprotocols; and a controller connected to the transceiver and thesatellite transceiver via the router, the controller being configured toestablish, using at least one of the transceiver and the satellitetransceiver, a telemedicine session with the operations center and theone or more medical facilities using a Transport Morphing Protocol(TMP), the TMP being an acknowledgement-based user datagram protocol;and mask one or more transient network degradations to increaseresiliency of the telemedicine session.

In an exemplary embodiment, the controller is configured to adjust datasend rate of the telemedicine session to reduce packet loss and reducethe resending of packets of the telemedicine session.

In an exemplary embodiment, the controller is configured to encryptcommunications of the telemedicine session such that the telemedicinesession is a secure telemedicine session.

In an exemplary embodiment, the first di-pole antenna element includesfirst and second vertically-arranged antenna radiators, the firstvertically-arranged antenna radiator being arranged orthogonal to thesecond vertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other.

In an exemplary embodiment, the second di-pole antenna element includesfirst and second horizontally-arranged antenna radiators, the first andthe second horizontally-arranged antenna radiators being arranged in asame horizontal plane.

In an exemplary embodiment, the first di-pole antenna element includesfirst and second vertically-arranged antenna radiators, the firstvertically-arranged antenna radiator being arranged orthogonal to thesecond vertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other; and the second di-pole antennaelement includes first and second horizontally-arranged antennaradiators, the first and the second horizontally-arranged antennaradiators being arranged in a same horizontal plane.

In an exemplary embodiment, the first and second di-pole antennaelements are enclosed in a single radome.

In an exemplary embodiment, the telemedicine system further comprises araman spectroscope configured to perform molecular analysis by ramanspectroscopy and/or other molecular diagnostic techniques, the molecularanalysis being performed on at least one of: serum, plasma, blood, bloodcells, cerebrospinal fluid, urine, cells, and tissue, wherein thecontroller is configured to diagnose and define, based on the molecularanalysis, at least one of: acute stroke, acute stroke subtype,concussion, and traumatic brain injury.

In an exemplary embodiment, the molecular analysis increases theprecision of the diagnosis.

In an exemplary embodiment, the satellite transceiver comprises a VSATmodem connected to a flat panel phased array terminal comprising atleast one satellite antenna configured to communicate over Ku or Kabands.

In an exemplary embodiment, the satellite transceiver comprises anL-Band satellite modem connected to an L-band satellite antenna; therouter being connected to both the VSAT modem and the L-Band satellitemodem; the controller being configured to monitor signal strength of theVSAT modem and the L-Band modem and to cause the router to dynamicallyswitch between the modems based on the monitored signal strengths.

In an exemplary embodiment, the telemedicine system further comprises a2D and 3D carotid Doppler and transcranial Doppler that are connected tothe telemedicine system.

In an exemplary embodiment, the telemedicine system operates in avehicle in a rural, extreme rural, urban, maritime or aviationenvironment.

In an exemplary embodiment, the vehicle is selected from the groupconsisting of ambulance, helicopter, bus, train, car, boat, oil rig, andairplane.

In an exemplary embodiment, the telemedicine system further comprisesone or more devices used to evaluate vitals and/or brain condition of apatient that are connected to the telemedicine system, and thetelemedicine system is configured to collect and transmit audio, videoor other data from the one or more devices to the operations center.

In an exemplary embodiment, the one or more devices is a EEG device,intracranial pressure measurement device, blood pressure measurementdevice, brain hemorrhage diagnostic device, non-brain diagnostic device,blood diagnostic test device; bodily fluid diagnostic test device, or acombination thereof

In an exemplary embodiment, the collected and transmitted audio, videoor other data is reviewed in real-time by at least one physician todiagnosis and/or treat the patient suffering from stroke, a traumaticbrain injury, a neurological disorder, an organ system medical disorder,or a combination thereof

In an exemplary embodiment, the controller is configured to implement anenhanced transport layer that mitigates high-latency of packets acrossat least one satellite link and at least one cellular wireless link, andprovides Quality of Service (QoS) and wide-area network (WAN)optimization across the at least one satellite link and the at least onecellular wireless link, and wherein the operations center is configuredto provide real-time communication between at least one medicalpersonnel in a vehicle with the telemedicine system, the at least onephysician, and at least one medical personnel at a receiving hospital.

In an exemplary embodiment, the telemedicine system further comprises atleast one teleconferencing solution, the at least one teleconferencingsolution is connected to the telemedicine system at an applicationlayer, and rides on top of fully redundant physical, network andtransport layers with no single point of failure and with at least99.99% availability.

BRIEF DESCRIPTION OF THE FIGURES

The accompanying drawings, which are incorporated herein and form a partof the specification, illustrate the aspects of the present disclosureand, together with the description, further serve to explain theprinciples of the aspects and to enable a person skilled in thepertinent art to make and use the aspects. The drawings are forillustration purposes only and are not necessarily drawn to scale.

FIG. 1 illustrates a telemedicine system environment according to anexemplary embodiment of the present disclosure.

FIG. 2 illustrates a telemedicine system according to an exemplaryembodiment of the present disclosure.

FIGS. 3A and 3B illustrate a telemedicine system according to anexemplary embodiment of the present disclosure.

FIG. 4 illustrates a telemedicine system according to an exemplaryembodiment of the present disclosure.

FIGS. 5A-5K illustrate antenna systems according to exemplaryembodiments of the present disclosure.

FIG. 6 illustrates an example emergency response sequence according toexemplary embodiments of the present disclosure.

FIG. 7A illustrates an emergency response using a telemedicine systemaccording to exemplary embodiments of the present disclosure.

FIG. 7B illustrates an emergency response using a telemedicine systemaccording to exemplary embodiments of the present disclosure.

FIG. 8 illustrates a network for the telemedicine system according to anexemplary embodiment of the present disclosure.

FIGS. 9A and 9B illustrate a network for the telemedicine systemaccording to an exemplary embodiment of the present disclosure.

FIG. 10 illustrates communication paths for an emergency responseaccording to an exemplary embodiment of the present disclosure.

The exemplary aspects of the present disclosure will be described withreference to the accompanying drawings. The drawing in which an elementfirst appears is typically indicated by the leftmost digit(s) in thecorresponding reference number.

DETAILED DESCRIPTION

In the following description, numerous specific details are set forth inorder to provide a thorough understanding of the aspects of the presentdisclosure. However, it will be apparent to those skilled in the artthat the aspects, including structures, systems, and methods, may bepracticed without these specific details. The description andrepresentation herein are the common means used by those experienced orskilled in the art to most effectively convey the substance of theirwork to others skilled in the art. In other instances, well-knownmethods, procedures, components, and circuitry have not been describedin detail to avoid unnecessarily obscuring aspects of the disclosure.

As an overview, the present disclosure provides a systems and methodsfor assessing a patient for one or more traumatic brain injuries, suchas for a stroke, and other neurological disorders while in transport inan emergency vehicle, such as an ambulance, emergency helicopter,airplane, train, boat and/or other vehicle. The disclosure is notlimited to in-transit assessments and can include assessing a patient ina diagnostic facility such as an urgent care facility, doctor's office,clinics, nursing homes, fire station, police station, or anotherfacility. The telemedicine system can also be a portable configurationthat can be brought into a facility by emergency personnel whenassessing a patent.

In the treatment of a medical condition (e.g., stroke), adverse factorsrelated to time-sensitive, early, reliable, accurate, and safe strokediagnosis and therapy affect the outcome of treatment. Expertneurological and neuroradiological examination with stroke telemedicineusing audio/video teleconferencing in hospital emergency departments,including stroke ready and primary and comprehensive stroke centers canbe used to reduce the time to definitive diagnosis, to initiation ofclot buster and/or clot removal, and improved prognosis (in some cases).Given the time critical nature of stroke diagnosis and therapy, aprehospital, cloud based solution can be implemented in ambulances orother emergency vehicles. As such, patients may be diagnosed earlier,have therapy initiated earlier, with neurological diagnosis at time ofinitial patient contact and a seamless continuum of care from pickup tohospital.

Strokes with large vessel obstructions (LVO) can include obstructions inthe middle cerebral arteries, the basilar artery, and the carotidartery. These strokes comprise about 30% of acute strokes and can causethe most severe neurological disability unless diagnosed and treatedearly, when appropriate. The earlier the diagnosis and the earlier thetreatment, if warranted with clot buster and/or clot retrieval,particularly with stent retrievers, the better the chance of reversal orneurological abnormalities and stroke or reduced neurological disabilityor death risk. Prehospital diagnosis, delivery to the appropriatefacility, and preparation and expertise at the target hospital facility,particularly a comprehensive stroke center, is crucial for the acute andfuture prognosis of the patient. In the exemplary embodiments describedherein, the pre-hospital environment, including ambulances and othervehicles and urgent care centers, is optimized to identify large vesselobstructions and foster earlier and appropriate therapy.

Stroke, including early onset stroke before age 55 years, is predisposedto by, including but not limited to prior stroke, prior heart attack,rhythm disturbance of the heart, diabetes, obesity, race, high lipids,genetic disorders that cause stroke (including molecular abnormalities),and complicated migraine. Early identification of patients with thesepredisposing disorders by neurological examination and non-invasive neckand brain blood vessel screening with ultrasound may lead toidentification of patients at risk for impending stroke, as well asinitiation of therapies that may be useful in preventing stroke, i.e.high blood pressure, high lipid or heart rhythm disturbance management.In exemplary embodiments, telemedicine systems and method can be used inhospital or in outpatient settings for patient management.

Seizures with or without residual weakness and other neurological signsand symptoms can mimic strokes. The acute therapy for these is verydifferent than for strokes and diagnosis of stroke in these situationsmay lead to treatment with clot buster. The latter has 4-10% risk ofbrain hemorrhage in all cases and would not be warranted in seizurecases. Neurological examination in the acute situation as well as EEGtied to the telemedicine system may be useful and diagnostic.

Traumatic brain injury (TBI) and stroke may have increased intracranialpressure, which is needed for diagnosis and potential acute and subacutetherapy. In addition to the transcranial Doppler, ultrasound measures tolook at pressure on the eye nerve as well as separate devices thatmeasure intracranial pressure externally may be employed with thetelemedicine system.

Trauma, stroke, traumatic brain injury (TBI), other acute neurologicaldisorders, and other clinical disorders may need emergent or urgent careor home or clinic diagnosis. Devices that look at the ear for blood orinfection (e.g., an otoscope), the mouth for conditions, including butnot limited to pharyngeal inflammation and trauma, can be interfacedwith telemedicine systems. The same is true for stethoscopes forevaluation of the heart and lungs, which can be interfaced withtelemedicine systems. Similarly, ophthalmoscopes can be interfaced foreye conditions and increased brain pressure, reflected in the eye nerve.Electrocardiography can also be interfaced with telemedicine systems.

A primary barrier for giving clot buster in stroke early andpre-hospital situations is the need for a CT scan, which is used todetermine if there is a brain bleed. The latter is an absolutecontraindication to clot buster. The presence of hemorrhage starts adifferent treatment protocol potentially in ambulance and at thehospital. As explained in the various exemplary embodiments herein, thetelemedicine systems and methods ameliorate these issues.

Telemedicine can include the use of telecommunication and informationtechnology to support health care when distance separates the patientfrom the caregiver. Telemedicine has been fostered by the development ofcomputer and connectivity equipment and software, dedicated ITdevelopment and support at hospitals, advanced software fortelemedicine. Telemedicine may involve wide area networks (WAN), localarea networks (LAN) Internet, private and public networks, virtualprivate networks, wired and/or wireless networks, municipal wirelessand/or wired broadband networks, cellular networks, metropolitannetworks. Telemedicine networks can be implemented in concert with hoststhat may involve any device, including a computer. These devices mayinvolve security tools, particularly in a clinical environment.

Initiation of telemedicine can include Tele-stroke diagnosis andmeasurements. The quality and definitive telemedicine in an ambulancedepends on WiFi, commercial wireless carriers, and associated dependenceon cell towers, results in connectivity issues, including, for example,the inability to connect, persistent connectivity, signal loss,bandwidth availability and quality of service. These issues can be moreprevalent within rural regions and busy urban areas and quality audioand video may be reduced. Other types of data transfer, including imagesmay also have limitations in this setting. For example, sometelemedicine implementations have been tested and have only achievedconsultation success rate of approximately a 40%. This success rate wasimpacted by connectivity initiation and persistence, as well as poorquality audio and video. The deployment of ambulance systems thatinclude mobile CT scanner devices have also experienced these issues ofconnectivity degradation, bandwidth, poor quality audio and videotransmissions, and low success rates.

The exemplary embodiments described herein are directed to hardware andsoftware solutions for improved telemedicine, having more effective andreliable connectivity. As described herein, ambulance telemedicinesystems for stroke, TBI, and other neurological conditions may addressand diagnosis at the time of first response, transport to theappropriate medical facility (e.g., hospital), and allow for thepreparation for rapid definitive intervention with the appropriatediagnosis, personnel, & equipment for treatment when the patient arrivesat the emergency facility.

The systems and methods of the present disclosure can perform remoteneurological examination and determination of parameters indicative of,for example, a possible stroke or a stroke risk patient. The results ofthe assessment allow for a patient to then be redirected to the neareststroke treating hospital, thus saving valuable treatment time, allowingthe preparation for, and evaluation of, the safest and most appropriatediagnosis and treatment. As would be understood by one of ordinary skillin the relevant arts, this disclosure is not limited to brain injuriessuch as strokes, and can be applied to other medical conditions.

In exemplary embodiments of the present disclosure, the system andmethods include telemedicine and an ecosystem of care for stroke,traumatic brain injury and other neurological disorders and trauma forclinical and neurological examination and determining blood flowvelocity and brain neck vessel obstructions, and/or generate one or moremedical images of the patient using one or more imaging modalities.

The telemedicine system can include measurement devices configured toperform high quality, telemedicine neurological or non-neurologicalexaminations in real time, visualize and capture audio input directly,collect measurements for brain and neck vessel function and physiology,and deliver integrated care for a patient in emergency vehicles (e.g.,ambulances), acute care situations, and also non-emergent carelocations.

In exemplary embodiments, the clinical examinations, including, but notlimited to, the National Institute of Health (NIH) Stroke Scale,neurological examination, and/or other clinical examination data relatedto brain and other organ systems, and/or the measurements are collectedwhile the patient is in transport, including the electronic healthrecord of the patient with the examination results (e.g., in text formatand by audio/video communication) and the measurements are sent to anoperations center and/or more neurological and/or radiological expertsat one or more remote locations, using advanced health informationtechnology techniques. The operations center and/or neurological andradiological teams can analyze the measurements and/or one or morepatent images to determine whether a stroke has or is occurring, and canprovide instructions to the transport team. The operations center canalso communicate with one or more emergency vehicle control centersand/or or medical facilities to determine the appropriate facility toroute the emergency vehicle to.

In an exemplary embodiment, a textual electronic health record withexamination information and interpretation of other physiologicalmeasurements are provided to the ambulance personnel, the appropriatehospital to which the patient will be transported, and stroke and otherpersonnel at that facility. This allows for the patient can betransported to the appropriate facility and for preparations anddecisions to be made prior to the transport's arrival.

Upon arrival at the appropriate facility (e.g., hospital or emergencyroom), warranted and appropriate medical (e.g., stroke) diagnostics andtreatments can begin immediately, thus saving valuable time. Therapy forthe patients can be selected and increase the positive outcomes,including stroke reversal and reduced stroke severity, as well asreducing mortality. In assessing stroke, identifying abnormalities orreduced blood flow in neck or brain blood vessels are important becauseof the associated urgency with addressing these conditions.

In exemplary embodiments, one or more imaging modalities can be used toassess the patient, including ultrasound imaging such as, carotid and/ortranscranial Doppler, photoacoustic spectroscopy, and phased arrayultrasound. The Doppler imaging can include both two-dimensional (2D)and three-dimensional (3D) imaging, transcranial Doppler (TCD), and/ortranscranial color coded Doppler (TCCD). The imaging modalities are notlimited thereto and can include, for example (but not limited to),computed tomography (CT) imaging, positron emission tomography (PET)imaging, single-photon emission computed tomography (SPECT), X-rayimaging, magnetic resonance imaging (MRI), nuclear magnetic resonanceimaging (NMRI), magnetic resonance tomography (MRT), raman spectroscopy,and/or another imaging technology as would be understood by thoseskilled in the relevant arts.

In an exemplary embodiment, the imaging device can be configured totransmit energy to a region of interest, such as in the patient's headand neck regions and/or cranial and carotid regions. In someembodiments, ultrasound transducers can be placed on the patient totransmit and sense ultrasound waves to characterize a patient's brainand measure blood parameters. The imaging devices can collect ultrasonicwaves and process the corresponding data to assess the patient (e.g.,blood flow velocity). In exemplary embodiments, the telemedicine systemcan be configured to measure molecular indices to assess the patient inaddition to, or as an alternative to capturing a medical image.

In operation, the telemedicine systems of the present disclosure can beimplemented in an emergency vehicle and can be configured to collectdirect visual and audio information and direct Digital Imaging andCommunications in Medicine (DICOM) and other modality information aboutthe blood flow in the head and neck region of the patient. Thetelemedicine systems can be configured to transmit the correspondingdata to a remote location, such as an operations center of thetelemedicine system and/or a medical facility (e.g., hospital).

As discussed further below, the telemedicine systems of the presentdisclosure can also be used to collect and transmit direct visual andaudio information and data from other devices that reflect on brainfunction and other organ systems. Thus, the systems and methods of thedisclosure provide remote, real-time, stroke diagnostics, as well asdiagnostics applicable to other disorders that may mimic stroke or thatmay affect neck and brain blood flow, such as heart attack or diffuseinfection (sepsis) or traumatic brain injury and concussions. Thesystems and methods of the disclosure are integrated into a telemedicineecosystem, allowing for brain damage to be evaluated in real-time uponfirst-contact with patients, with a particular focus on definitiveneurological examination and the narrowing or obstruction of large neckand brain blood vessels. Systems and methods of the disclosure captureneurological and neuro-vascular information and data that is rapidlytransmitted to a data and operations center for analysis by licensedneurologists, radiologists, and related professionals.

Transmitting 3D and 2D images of carotid and other neck arteries, andcollecting blood flow velocities and other parameters on large or mediumsized brain bloods vessels, and during patient transport, the systemsand methods of the disclosure allow professionals to render a diagnosis,inform Emergency medical technician (EMT) personnel, and alert anddiscuss with the appropriate emergency room or stroke center to preparefor the pre-diagnosed patient. Thus, the present disclosure helps todifferentiate among brain trauma, strokes, seizures, and intoxication,and hyper/hypoglycemic events, so that patients arrive at the rightlocation, already diagnosed, saving valuable time and preventing theloss of up to two-million brain cells per minute in the event of asevere stroke.

In one or more embodiments, the systems and methods of the disclosuredeliver energy to a region of interest through a patient's head and neckregion. In some embodiments, energy may be delivered by an ultrasounddevice.

Thus, the devices and methods of the disclosure can be used topreventatively identify pre-stoke and stroke conditions that can lead tolife-saving interventions-ranging from immediate removal of vascularobstructions to less invasive dietary and lifestyle changes. The presentdisclosure helps assure rapid treatment that saves lives, brain cells,expensive and time- consuming rehabilitation. In addition, pain,suffering, and other deleterious brain-related consequences are reduced.

Exemplary embodiments include system and methods for diagnosing strokes,traumatic brain injury, other neurological disorders, and other clinicaldisorders in patients acutely in prehospital environments, andpotentially, preventatively. The devices, systems, and methods alsoidentify and define vessels abnormalities in patients in preventativesettings that are at stroke risk. There are two types of strokes:hemorrhagic or ischemic. An ischemic stroke occurs as a result of anobstruction within a blood vessel supplying blood to the brain. Itaccounts for 87 percent of all stroke cases. A hemorrhagic stroke occurswhen a blood vessel ruptures and spills blood into brain tissue. Thetreatment approaches are different for stroke without hemorrhage versusstroke with hemorrhage. For example, stroke patients without hemorrhagemay require vessel opening therapies with intravenous thombolytics orintra-arterial clot busters (e.g., tissue plasminogen activator (tPA))or catheter-based interventional clot removal. The latter treatments aredangerous and not warranted for hemorrhagic stroke.

Treating an acute stroke patient is time sensitive. However, manypatients do not receive the required medical attention in time. Thepresent invention provides devices and methods for early detection anddiagnosis of stroke patients to afford the possibility for appropriateand safe treatment modalities acutely and to limit the occurrence ofsecondary complications, including brain hemorrhage. Further, thisdevice provides a simple means for application to collect physiologicaldata without significant technical expertise or time commitment byemergency technical providers. Thus, a patient may be recognized assuffering from cardiac arrest, but the presence of a stroke may goundetected.

An ischemic stroke is the result of neuronal death due to lack ofoxygen, a deficit that produces focal brain injury. This event isaccompanied by tissue changes consistent with an infarction that can beidentified with neuroimaging of the brain. Strokes are usuallyaccompanied by symptoms, but they also may occur without producingclinical findings and be considered clinically silent.

Both acute and chronic conditions may result in cerebral ischemia orstroke. Acute events that can lead to stroke include cardiac arrest,drowning, strangulation, asphyxiation, choking, carbon monoxidepoisoning, and closed head injury. More commonly, the etiology of strokeis related to chronic medical conditions including large arteryatherosclerosis, atrial fibrillation, left ventricular dysfunction,mechanical cardiac valves, diabetes, hypertension and hyperlipidemia.

Regardless of the cause, prompt recognition of symptoms and urgentmedical attention are necessary for evaluation and institution ofclinically warranted thrombolytic or clot busting therapy through theveins or catheter and stent retriever related intra- arterial clotbusting therapy or clot removal to be considered and provided.

Time is of the essence for beginning therapy and performing suitableevaluations. Clinical imaging and other testing may be performed duringthat time. Because time is so critical for performing neurologicalexamination, imaging and other testing needs to occur during a criticaltime window. This has prompted increased education and awarenesscampaigns for the public and emergency services providers about thesigns and symptoms of stroke. This has also established nationalprotocols for acute stroke diagnosis and treatment to be adopted atincreasing number of United States hospitals and their emergencydepartments. The present disclosure is built on novel enhancement ofexisting established National protocols. The arrival of a stroke patientin the emergency room (ER) must be viewed as a true emergency, and thepatient should receive the highest priority. On arrival to the ER,identification of the patient with a potential stroke should prompt thecollection of several important data points: time the patient was lastknown to be neurologically normal; detailed neurological exam, includingthe use of National Institutes of Health Stroke Scale (NIHSS);determination of the neurological diagnosis and the severity of theneurological dysfunction; time known to last be neurologically normal;serum glucose level; general metabolic screening; blood count and bloodclotting status screening; recent and remote medical and neurologicalhistory, with particular attention to diabetes, hypertension, recentsurgery or head injury; prior bleeds in brain and other tissues, andepilepsy; current medications, allergies, and baseline CT scan of headfor stroke, hemorrhage or other condition. Potential stroke anddetermination of risk and eligibility or clot buster or interventionbrain or neck artery therapy are derived from this evaluation. Rapid,safe and appropriate therapy for specific patients is fostered by rapidassessment as documented above.

The American Heart Association standards mandate for evaluation of clotbuster and endovascular therapy, a neurological examination thatincludes a NIH stroke scale, a CT scan to evaluate for stroke, strokesize, and presence or absence of brain hemorrhage, as well as vesselimaging of neck and brain. Protocols for stroke evaluation and/ortreatment may be variable across centers of similar type, i.e. primarystroke centers or comprehensive strokes centers or primary strokecenters that do not have full stroke treatment capacities (endovascularcapabilities for clot retrieval versus no capacity), primary strokecenters versus stroke ready vs. non-stroke ready hospitals, versuscomprehensive stroke centers.

Recently, since neurological evaluation with stroke specialists may notbe uniformly available rapidly or geographically, stroke telemedicineusing tele-neurologists at remote locations with special mobile audiovideo equipment in the Emergency Department or other settings canprovide review of all relevant data, neurological examination, and CTscan review, while advising Emergency physicians about appropriate andsafe therapies. Efficacy and quality of the neurological examination andradiological interpretation by offsite neurologists is similar; strokeidentification and time to deliver clot buster to appropriate patientsand the occurrence of clot buster side effects (e.g.,. hemorrhage) issimilar to hospitals that have regular in person neurologicalevaluation. This is helpful within the time window and similar inconcept to the rapid determination of neurological examination andphysiological measures pre-hospital in the current application.

In exemplary embodiments of the present disclosure, the systems andmethods can include a telemedicine solution for ambulances that combinesunique proprietary and standards-based products delivering uninterrupteddata signals between telemedicine equipped ambulance and critical-careproviders. In an exemplary embodiment, dual di-pole antennas providecontinuous Physical layer signaling to mobile endpoints (ambulances)regardless of terrain, locality, and available cellular provider.

In exemplary embodiments, the Transport layer protocol of the OSI modelprovides application persistence even in low coverage and highlycongested situations with reduced losses in connectivity. This transportlayer protocol can also be configured to be plug-and-play ready.

In exemplary embodiments, the systems and methods include a high-qualityaudio/video platforms (hardware and/or software) which are agnostic andcan be easily interfaced with other software and hardware, and with easeof use can be combined with a software vehicle; special, ruggedizedrouter; a ruggedized laptop; and/or specialized antennas. Theembodiments described herein can be implemented in both rural and urbanenvironments, in forward military positions, and in maritimeenvironments (including, but not limited to, ships and oil rigs andaviation environments) for stroke and other telemedicine systems, and beused in fast moving (e.g., up to approximately 90 miles per hour)emergency vehicles (e.g., ambulances) and in aviation vehicles(including, but not limited to, planes and helicopters).

In an exemplary embodiment, neurological examination and physiologicalmeasurements can be performed using carotid and transcranial Dopplerdevices. The measurements can be performed in real time by telemedicineto operations centers staffed by expert tele-radiologists andtele-neurologists that also provide real time analysis to allow forstroke patient transport to appropriate stroke centers that are preparedto provide rapid diagnostics and appropriate and warranted treatment.

In exemplary embodiments, an ambulance personnel or EMTs (EmergencyMedical Technicians) can evaluate a stroke in the field or on theambulance's way to a medical facility. The ambulance can be outfittedwith a telemedicine system configured to send valuable telemetry to themedical facility ahead of the patient's arrival. In exemplaryembodiments, the operations include dispatching an ambulance to thepatient. A neurological examination using, for example (but not limitedto), the NIH stroke scale would be performed. A Transcranial Doppler ofBilateral Middle Cerebral Arteries and Carotid Arteries and then BasilarArtery can be performed. These arteries are the large arteries that cancause the most severe stroke and that would be amenable to intravenousor intra-arterial therapy. In exemplary embodiments, depending on thelength of the ambulance ride, the neurological examination andultrasound examinations could be repeated or could be continuous toprovide ongoing data about the patient during transport.

The data can be sent to an operations center where it would be rapidlyprocessed. The processed data would be rapidly evaluated by experiencedneurologists and radiologists at the operations center at a power ofcare and in real time, 24-7. The analysis of this data would be providedto the ambulance, providers at the stroke center or hospital oremergency room, including neurologists and radiologists. A decisionwould then be made as to the hospital destination for the ambulance thatwould maximize care quality, specific imaging and expert availability,and reduce time to evaluation and therapy. Further, preparation ofimaging needs, clot buster mixing, other protocol requirements fordiagnostics, and preparation of the angiography suite and personnel forrapid intra-arterial clot buster or clot retrieval would be promoted bythis plan. This can be done prior to the patient's arrival at themedical facility and emergency department. The embodiments foster alogistical operation that would reduce time and maximize potentialappropriate therapy, reduce risk, and improve patient prognosis.

In exemplary embodiments, a system architecture of software andhardware, and network management with an operations center have beenemployed and optimized to maximize audio video telemedicine as well asphysiological data transmission, i.e. ultrasound of brain and neck bloodvessels, by persistent connectivity in different environments, includingvariable bandwidth situations and low signal in rural and urbansettings.

Telemedicine can be applied to acute care with emergencies, non-emergentcare, and long-term care of neurological, neurosurgical and othermedical disorders. The type of monitoring can include real-time,store-and-forward and remote monitoring. “Store-and-forward” is definedas asynchronous transmission of medical information that can be accessedat a later date or for immediate processing. As would be understood bythose skilled in the art, store-and-forward corresponds to when thepacket source, destination and CRC checksums are validated before thepacket is forwarded on the wire. Cut-through refers to data that is notvalidated as to data integrity prior to forwarding across the wire.Cut-through can be faster than store-and-forward but has an increasedrisk of corrupt/useless packets and so data packets frequently must beresent due to errors. The stored data can be used for later orsimultaneous big data analysis

The telemedicine system can include exchanging images, videos and audioinformation. Real-time telemedicine can include the synchronous transferof medical information between two or more parties, such as anambulance, operations center, medical facility, and/or one or moretele-physicians. The exchange can include live audio/videoteleconferencing or the use of medical devices to assess patientsclinically or physiologically. In real-time telemedicine, bidirectionalcommunication is essential and demands the received data matches thedata sent and must include persistent connectivity and mitigatedlatency.

In exemplary embodiments, real-time telemedicine can be applied to acuteneurological and other medical disorder situations. Real-time andstore-and-forward transmissions will be applied to chronic or outpatientcare for the system and methods. Bidirectional real-time audio/videotelemedicine can be utilized with central coordination at an operationscenter between patient location in an ambulance or at an urgent carefacility, neurology and radiology experts, and an appropriate receivinghospital and emergency medicine and neurology and radiologyprofessionals and ancillary services at the receiving hospital.

Brain and neck imaging modalities can be used for the rapid evaluationof stroke. At the time of stroke, mini-strokes, suspected strokes, ortransient ischemic attacks (TIAs), a CT scan of brain can be performedto look for bleeding or brain hemorrhage, stroke presence and size, orother diagnosis. Under normal results, treatment decisions are based onneurological examination. When a hemorrhage is present, the patientfollows a different but rapid treatment pathway. Embodiments within thisdisclosure provide systems and methods to distinguish stroke withhemorrhage from stroke without hemorrhage, using, for example (but notlimited to), phased array, carotid and/or transcranial Doppler andphotoacoustic spectroscopy.

Typically, a CT scan of the brain is routinely available in mosthospitals. Reading of the data may or may not be available or availablewithin the required time frame. Telemedicine systems with CTs canprovide information in advance and in the prehospital period. Inhospitals, magnetic resonance imaging (MRI) of the brain (intracranial)is more sensitive and specific for stroke and for therapy riskassessment for stroke than CT scan for stroke presence and severity andtherapy risk evaluation, but in the majority of hospital and emergencysettings, MRI is not physically available or with rapid expertinterpretation rapidly, i.e. within 15-20 minutes and is expensive. Thetelemedicine systems and methods of the exemplary embodiments can beused alone or in combination with CT and/or MRI imaging to provide asensitive and specific means to determine appropriate rapid therapiesfor acute stroke and help to delimit risk. The exemplary embodimentsprovide imaging methods for distinction of stroke with brain hemorrhagefrom stroke without hemorrhage that would affect the type of treatment,while also saving time.

In exemplary embodiments, 2D and 3D carotid Doppler and transcranialDoppler can be employed in pre-hospital evaluation and can replacevessel imaging in multiple circumstances. The system and methods of theexemplary embodiments can be used to look for blood vesselabnormalities, including stenosis and obstruction of the main brainarteries, including the middle cerebral arteries and basilar artery, andneck arteries, carotids, as a basis for stroke and for specificintravenous clot buster therapy and intra-arterial clot buster orcatheter based clot retrieval therapy.

FIG. 1 illustrates a telemedicine system environment 100 according to anexemplary embodiment of the present disclosure.

In an exemplary embodiment, the telemedicine system environment 100includes an emergency vehicle 102 that is communicatively connected toan operations center 120 via a network 110. The emergency vehicle 102can include ambulances, emergency helicopters, airplanes, and/or othervehicles as would be understood by one of ordinary skill in the relevantarts. The vehicle may include a motor (e.g., an engine), a windshield,at least four wheels, at least two axles, a body or frame, and a motorpower source (e.g., a battery and/or a fuel tank). Vehicle can alsoinclude oil rig.

The network 110 can include one or more well-known communicationcomponents—such as one or more network switches, one or more networkgateways, and/or one or more servers. The network 110 can include one ormore devices and/or components configured to exchange data with one ormore other devices and/or components via one or more wired and/orwireless communications protocols. In an exemplary embodiment, thenetwork 110 is one or more backhaul networks, such as a cellularbackhaul network, Internet service provider network, GNSS backhaulnetwork, the Internet, and/or one or more other networks as would beunderstood by one of ordinary skill in the relevant arts.

The vehicle 102 can include a telemedicine system configured tocommunicate with the operations center 120. The telemedicine system caninclude measurement devices configured to perform high quality,telemedicine neurological examinations. For example, the telemedicinesystem can be configured to collect measurements for brain and neckvessel function and physiology. The telemedicine system can include amultimedia system, such as one or more cameras, displays andinput/output (I/O) devices configured to teleconference with one or moreoperating centers 120. A telemedicine system according to an exemplaryembodiment is described in more detail below with reference to FIG. 2.In an exemplary embodiment, the operations center 120 and thetelemedicine system 200 (FIG. 2) can include a teleconference solutionto facilitate multimedia (audio/video) communications between thecomponents within the telemedicine system environment 100. In anexemplary embodiment, the teleconference solution can include Polycom™'sRealPresence Platform by Polycom, Inc., other Polycom-based platforms orthe like, that assure communication, telemedicine note construction,connectivity, redundancy, quality of service within a broad bandwidthrange (including lower bandwidths), platform quality, cellular wirelessand/or satellite compatibility; carotid and transcranial Doppler and/orother diagnostic devices and/or their associated software compatibility.In the exemplary embodiment, the telemedicine system can use theaforementioned teleconferencing solutions at the application layer;however, those applications ride on top of the fully redundant physical,network and transport layers, which are designed as a complete system,with no single point of failure and with 5-9s (99.999%) availability.The telemedicine system can maintain a video resolution high enough toeffectively evaluate a patient remotely, and such video resolution is atleast 80-128 Kbps of streaming IP. Communication and other telemedicineapplications can be used individually or concurrently with differenttelemedicine platform options. In an exemplary embodiment, thetelemedicine system is an integrated information, data transfer, andanalysis solution that includes a webcam-equipped, ruggedized laptopwith software including, but not limited to, video teleconferencing,EHR/EMR, ultrasound with the ability to scan and render in 3D, carotidand transcranial Doppler images, and/or an enhanced transport layersoftware that (i) mitigates high-latency of packets across at least onesatellite link and at least one cellular wireless link and (ii) providesQuality of Service (QoS) and wide-area network (WAN) optimization acrossthe at least one satellite link and the at least one cellular wirelesslink. The enhanced transport layer software can be, for example (but notlimited to), an enhanced software that is a streaming protocol (e.g.,User Diagram Protocol (UDP))-based and allows sending local TCPacknowledgements (ACKs) to a computer or a mobile device on eachendpoint of the WAN connection so it appears at each endpoint that thereis sub-millisecond latency between the computer or mobile device on eachendpoint of the WAN connection. As another example, the enhancedtransport layer software can be the L4 software from Circadence or thelike. Additionally, interfaces are required for connecting digitaltools, such as an otoscope, stethoscope, EEG, EKG, etc. Dual LTE dipoleantennas, dual environmentally-hardened routers and/or power supplieswith interfaces to connect satellite modem/router, a flat-panel VSATantenna or BGAN antenna with associated modem/router can also beconnected to and including in the telemedicine system. The telemedicinesystem also includes an operations center and/or software associatedwith the operations center that can alert medical personnel (including,but not limited to, emergency medical technicians (EMTs), medics, combatmedics, physicians (e.g., formal neurological, radiological, surgical orother medical specialty consults), physician's assistants, nurses.medical students, and medical technicians (e.g., radiology technicians;blood technicians; lab technicians)) in the ambulance and at thehospital. The contents of the telemedicine system's clinical evaluationand consultation can be shared from the operations center in real timewith the ambulance personnel/medical director and the receiving hospitalphysicians and stroke center physicians and their other personnel bydirect audio-video telemedicine communication and faxing orelectronically delivering a consult note to the receiving hospital. Theconsult notes along with other physiological and clinical data can beadded to the hospital medical record or electronic health record andstored securely at the operations center and data warehouse. The latterstored information can be used for later big data analytics.

In operation, the vehicle 102 can communicate with one or more medicalfacilities (e.g., hospitals) 140, emergency vehicle control or dispatchcenters 142, and/or medical physicians 144 (e.g., tele-physicians). Thevehicle 102 can communicate with one or more of these entities via theoperations center 120 and/or can be configured to communicate directlywith one or more of the entities. In an exemplary embodiment, thetelemedicine system can be standalone system located at, for example(but not limited to), a facility 104, such as an urgent care center orother medical facility; a government building such as a fire station ora police station; and/or any facility as would be understood by thoseskilled in the relevant arts. The standalone system can be portable orimplemented as a stationary system.

In an exemplary embodiment, the telemedicine system of the vehicle 102can be configured to communicate with the operations center 120 vianetwork 110 and one or more wireless and/or wired communicationnetworks. For example, the telemedicine system of the vehicle 102 can bewirelessly connected to the network 110 via a wireless access point 108and/or a global navigation satellite system (GNSS) 106.

The wireless access point 108 can be configured to transmit and receivecommunications conforming to, for example (but not limited to), one ormore cellular communication protocols (e.g., LTE) and/or non-cellularcommunication protocols (e.g., WiFi). The GNSS 106 can include one ormore GNSS transceivers configured to communicate with one or more GNSSbase stations via one or more orbiting satellites. The GNSS basestations can be connected to the network 110.

In an exemplary embodiment, the connection between the vehicle 102 andthe operations center 120 can be conducted via a telemedicine platform,which may include one or both of broadband global area network (BGAN)and/or very small aperture terminals (VSAT) that utilize satellitetechnology. As shown in FIGS. 9A and 9B, vehicle 102 may be configuredfor telemedicine communication alternatively or in addition to any andall of the communication platforms described herein.

In some examples, BGAN and VSAT deployments can be used in rural,maritime, aviation and forward positons. These alternatives allow formobile antennas tied to land-based hosts and bidirectional flow to andfrom satellites. In an exemplary embodiment, satellite connectivityinvolves wireless broadband access from one or more host computersconnected to a satellite base station, up to one or more satellites andback to a second base station and computer(s). In an exemplaryembodiment, real-time video conferencing maximizes potential latencydelays and performance degradation due to the great distances betweenthe two endpoints via the satellite network, as these geostationarysatellites are at an altitude of 22,000 miles above the Earth. However,this may be the only available technology in forward military positions,in extreme rural regions with limited or no wireless coverage, inunder-developed countries, and as a redundancy solution when there issignal loss or changes in bandwidth or connectivity related to real-timemission critical clinical evaluation using 4G/LTE wireless solutions. Inone or more exemplary embodiments, satellite connectivity can beemployed in combination with other cellular communications to providefor connectivity and redundancy including but not limited to ruralenvironments, forward military positons, and in low bandwidthsituations.

Exemplary features of satellite connectivity via BGAN and VSATdeployments will now be described. The satellite connectivity may occurthrough a telemedicine system with connectivity. As described below,vehicle 102 may be configured for telemedicine connectivity and includeselements of a telemedicine system.

The present invention's connectivity and Quality-of-Service telemedicinehardware/software solution, with interfaces to existing cellular LTE andsatellite networks, allows for real-time, point-of-care evaluation inFirst Responder vehicles at up to 90 MPH and without limitation due toelevation, with immediate expert neurological and device-relatedphysiological, blood vessel/brain examination. The highly-resilienttelemedicine solution overcomes negative effects of transient,low-quality cellular connectivity encountered when traversing multiplecellular towers and multiple service providers at high-speed by maskingbrief outages to the endpoint software, preventing applicationre-authentication and application crashes. The same underlying transporttechnology mitigates the effects of high-latency links, optimizing theWAN connection, resulting in 2x to >10x increases in data transferrates. Dual-polarity external antennas and hardened routers are deployedcomplementing the transport layer software, which combined offer ahighly available mobile telemedicine solution. The end-to-end solutionis also highly secure, designed to prevent common man-in-the-middle andtraffic replay attacks. The system employs dynamic lossless compressionwhenever possible to reduce the amount of data sent over the WANconnection allowing high-quality video to traverse even sparse cellularcoverage areas. It also prioritizes traffic based on pre-defined metricswhereby mission-critical data always takes precedence over the WAN vs.lower priority traffic.

A satellite is a heavy object which goes around another object in spacerelated to the effect of mutual gravitational forces. Artificial, activesatellites focused on telecommunication and non-military applicationsare commercially available and fall into three categories, or zones,depending on their altitude above the earth's surface: Low Earth Orbit(LEO), Medium Earth Orbit (MEO) and Geostationary Orbit (GEO).

These satellites have transponders or communication channels and arecontrolled by operators through tracking, telemetry and command forearth stations and satellite control centers. Specific satellites andsatellite operator can be chosen and contracted with for specificnetworks. These satellites may be ground to ground, ground cross linkground, and ground to relay platform. Satellite communications are notrestricted by geographical location and operate at certain bands anddependent on angle, optimized for speed and mitigated effects of delay.The satellite link involves an uplink from transmitting earth station tosatellite, the repeater or satellite, the downlink from satellite toearth station or platform and the receiver or earth station. Frequencymodulation or phase variation is used. The link is optimized for path,atmospheric losses, ionosphere losses, antenna system losses, andlinking system losses. Some of the sources of noise include: man-madenoise, radiation from sun and moon. Rain and vegetation absorption.Communication includes analog signals, speech and video and digital,i.e. telemetry, data transfer. Satellite transponders and earth stationsoperate at certain bandwidths, which can be optimized. The BR systemwith satellites is shown in FIGS. 8, 9A, 9B, and 10.

LEO's sit closest to the Earth, up to 2000 kms distance from Earth. TheIridium constellation is the most notable of LEOs, operating at 780 kmsabove earth. LEO's offer the quickest round trip for a communicationsignal and so latency is at its lowest. Due to being closer to earth,each LEO satellite's coverage area of an area of Earth is smaller thanthe other two orbits, so a greater number of satellites are required tocover the same area that a MEO or GEO can. Iridium is the onlyconstellation that offers truly global coverage, including over thePoles. Iridium satellites communicate with each other in space via 10Mbit microwave links in order to ‘pass’ a signal transmission betweenthem in order to facilitate the path of that signal to its intendeddestination (Iridium teleport/remote device). MEO's most commonly sit inthe range of 19,000 kms to 27,000 kms distance from Earth. The mostcommon satellites in this orbit are for communications and navigation,the most well-known being the Global Positioning System (GPS). The O3bcommunications constellation is a very new addition to this orbit, itstechnology is advanced and offer from 250 Mbps to over 500 Mbps forindividual ground terminals. However, the equipment O3b use to providesuch a service is large and very expensive and certainly not for amobile environment.

GEO's are at approximately 36,000 kms directly above the equator,maintaining a geostationary orbit at a fixed location about the earth,moving with the earth rotation at the same rate. Life span of 15-20years due to the optimum amount of fuel that can be stored and used tomaintain a precise fixed position in relation to earth. GEO's are much‘larger’ in capacity (both size and the amount of data they can processand transmit) and the predominant purpose of their greater distance fromearth is to maximize the extent of their coverage area on the earth'ssurface (most GEO satellite ‘beams’ will operate as far toward the polesas approximately 12-15 degrees from the horizontal). Due to the distancefrom earth, only 3 Geostationary satellites placed equidistant from eachother are required to cover the earth's surface (excluding the Poles).

Communications satellites offer up voice-only services, basic compresseddata (email, weather reporting, etc.), machine-to-machine (M2M orM-to-M), basic broadband IP and up to very high IP data throughput.

Latency, or the time taken for a signal to travel from one point toanother, occurs in all forms of transmission (light, sound, etc.). Insatellite communication terms, latency is the time it takes for a signalto travel to the satellite and back down to earth. For geostationarysatellites, that latency is approximately 250-300 milliseconds. However,as IP data requires a pinged response each time an IP packet is sent totell the originator that the packet has been received, latency ismeasured as the whole round-trip, so in the case of geostationarysatellites, that is approximately 550-600 milliseconds.

The lower the look angle from the earth station to the satellite, themore sensitive the signal is to receiver noise due to atmosphericrefraction, earth's thermal emission, line-of-sight obstructions, signalreflections with the ground or nearby structures, and weather (cloudcover, snow, fog, rain—the effect of adverse weather on a satellitesignal is called rain-fade, which can affect the signal loss regardlessof look angle to the satellite). All these contributory factors alsohave a differing degree of impact on the various Radio Frequency (RF)bands, with L-band possessing the greatest ability to penetrate adverseatmospheric/weather conditions and Ka-band the least.

Geostationary satellites are also subject to solar or sun outages (whenthe sun is directly behind the line-of-site between the satellite andthe earth station, solar radiation is at its strongest point andinterferes with the satellite signal by distorting it. These incidentsoccur twice a year, affecting any specific location for less than 12minutes a day for a few consecutive days.

The satellite terminal may differ for stationary and mobileapplications. A BGAN terminal may be used for streaming IP services atup to 256 Kbps of bandwidth in a vehicle moving at high-speed.Otherwise, a software-tuned, flat panel array may be used for streamingIP services at 10s of megabits per second, while a vehicle is moving athigh-speed or while at rest.

In a mobile environment, the antenna system needs to be able to stay‘locked on’ to the satellite(s) regardless of direction, speed andangle. Therefore, antennas for mobile operating environments are‘stabilized’ and able to ‘track’ a satellite when the moving vehicleturns or speeds up, travels at speed or slows down. There are also oftenweight and size restrictions in a mobile environment, meaning mobilesatellite equipment needs to be small in comparison to satelliteequipment on a fixed site, which results in a restriction in capacity toprocess, send and receive data. Video transmissions systems (ntsc, paland secam), and encoding systems would follow Mpeg-2 and h.264/Mpeg-4AVC standards.

Mobile antenna systems can either be the omni-directional, domed antennacommon for lower bandwidth (up to 256 kbps), L-band service, orflat-panel, software-steered VSAT antennas capable of 10s of megabitsper second. Firewalls can operate at both the remote/mobile site and atthe hub/teleport site or anywhere within that private network.

In an exemplary embodiment, the telemedicine satellite application isaimed at emergency responders (such as ambulances, fire trucks) formobility hardware and corresponding service platforms.

Satellite communications provide ubiquitous coverage and serviceavailability with high reliability for communication. Performance isinsensitive to terrain (except for steep mountainous regions using GEOor MEO satellites; instead, LEO satellites must be used) or distance andtransmission costs are not distance dependent. Remote satelliteequipment is relatively quick and easy to install and satellite networktopology is flexible to easily add, move or delete remote sites.

The end user uses a modem that interfaces between the user's computerand an outside antenna with a transceiver (Block Up Converter or BUC andLow Noise Block Downconverter or LNB). The BUC is a power unit thatamplifies the signal and increases the frequency in order to send it upto the satellite. The LNB converts the received signal (from thesatellite) back down to an amplification and frequency manageable by theground based system (e.g., 12 GHz satellite transmission to 1 GHz sothat less is lost). The transceiver receives or sends a signal to asatellite transponder in space. The satellite sends and receives signalsfrom an earth station, or teleport, that acts as a hub for the system.Each end user is interconnected with the hub station via the satellitein a star topology. For one end user to communicate with another, eachtransmission has to first go to the hub station which retransmits it viathe satellite to the other end user's satellite terminal. Such satelliteterminals handle data, voice, and video signals.

The antennas and satellite terminals that deliver different satelliteservices include small portable BGAN terminals, VSAT terminals (verysmall aperture terminals), which include large footprint antennas andnewer flat panel arrays (geared towards the mobile applicationenvironment such as Aeronautical, maritime and land vehicles).

Small portable BGAN terminals can be highly portable terminals whichprovide connection to a computer and optional handset, globally(excluding the poles) via the Inmarsat L-band frequency network. Thereare a number of models available, and specifically for mobility theseare Cobham Explorer 325 and 727, Add Value Safari, Thuraya Voyager andHughes 9450. The Inmarsat BGAN network and these terminals are limitedsignificantly with the amount of data that may be accessed and the speedat which that data can be transferred.

Certain mobility BGAN terminals provide the greatest throughput (up to492 kbps standard IP and up to 256 kbps dedicated streaming on themove/384 kbps on-the-pause). Standard IP is based on best effort and thenumber of terminals being used in a given region. Inmarsat BGANrepresents a small form factor terminal, limited broadband speeds on acontended network (with even more limited scope for applying dedicatedbandwidth).

It should be noted here that the forthcoming Iridium NEXT/Certussatellite network and platform (estimated full network capacity in2019/2020) will offer higher data speeds (up to 1.2 Mbps MIR, withrealistic contended throughput being around 350-400 kbps) on a smallerterminal than BGAN.

In an exemplary embodiment, the cellular wireless components of thetelemedicine system can be combined with a satellite based network. Thecellular wireless is redundant and can automatically switch between cellcarriers and be interfaced with a hard-wired Ethernet network, providingconnectivity to the satellite terminal on the WAN-side and to the laptopon the LAN-side of the telemedicine solution.

In an exemplary embodiment, a satellite network can be applied to thetelemedicine system. This network can interface and combine with thecellular wireless network to provide expanded and potentially fullconnectivity and quality of service. Redundancy is promoted by bothcellular wireless and satellite networks that can work in environmentswith poor connectivity, including but not limited to highly utilizedurban networks or mountainous or other high altitude regions or remoteregions, that are not serviced or capable of cellular wireless. Bothsatellite and cellular wireless networks that are interfaced to thetelemedicine system can also interface with hard wired Ethernetnetworks.

In an exemplary embodiment, the system has been developed to work withtelemedicine programs that can operate with high quality audio and videoat bandwidths as low as 128 kbps with limited latency and fullconnectivity in a vehicle moving at high-speed.

VSAT (Very Small Aperture Terminal) will now be described. Differenttypes of services may be delivered using VSAT (either dedicated orshared services). For a mobility application, Ku-band and Ka-bandfrequencies are preferred and will offer differing levels ofavailability depending on the location the antenna is being used, thesize of the antenna and its associated RF equipment (primarily BUCpower), as well as environmental conditions (inclement weather affectingthe Ka frequency greater than Ku). Standard VSAT antennas are large (1.0m to 1.8 m) fixed or auto-deploy antennas, large relative to InmarsatBGAN terminals. However, this does not work for a mobile environment.For mobile communications, flat panel phased array antennas arerequired. There are a number of manufacturers of such antennas includingRaySat (Gilat), Phasor, ThinKom, and most recently, Kymeta. MultipleMbps are attainable. However, two drawbacks with VSAT antennas are:First, the technology is considerably expensive. Second, more satellitebandwidth is required for the same gain/data speeds. Further, the typeand size of any VSAT antenna and BUC power will depend on availabilityrequired, location of the requirement and data speeds required.

Current BGAN capabilities (up to 256 kbps streaming IP in movingvehicle) allow for telemedicine applications to be deployed in mostenvironments. However, BGAN terminals connect to GEO satellites, whichquickly lose signal when the terrain in which they are deployed becomesmountainous. In such environments, a flat-panel antenna (e.g., Kymeta'smTenna) connecting to LEO satellites is required. Bandwidths of 10s ofmegabits per second can be maintained, even while travelling athigh-speed.

As with VSAT antennas, there are different types of services that may bedelivered using different types of satellite ‘platforms’ and associatedmodems (modems are not generic/ubiquitous and only work with specificplatforms). Three of the most widely used VSAT satellite platformsglobally are iDirect, Hughes and Gilat.

When trying to transmit multi-Mbps data to/from a satellite in bands >10GHz (Ku- and Ka-band), the path loss through the atmosphere and RFparameters mean that as much gain as possible is wanted. This is why themost economical solutions for high capacity two-way satellite throughgeostationary transponder capacity involve 1.8 to 3.0 meters-size dishantennas. VSAT needs at least 10 times more gain than BGAN, butattainable data speeds are far higher compared with L-band BGAN.

In an exemplary embodiment, the ambulance roof and its size has beenused as a basis for easily affixable satellite terminal/antennas (BGAN),with automatic pointing features, for mobile applications fortelemedicine and other data transfer. In the exemplary embodiment, VSATwith non-automatic pointing and automatic pointing can be deployed aspart of the system in stationary environments, including during setupambulance before transport. In the exemplary embodiment, interface withestablished global satellite platforms with ease of interfacing, qualityof communication, and also maximal attainable Mbps.

Referring to FIG. 8, a network system 1000 enabling the fulltelemedicine solution include, at the hardware layer, of redundant,hardened, LAN/WAN routers 1001 with multiple Ethernet and cellular4G/LTE ports. Connecting the dual routers are dual di-pole LTE antennas1001 a, 1000 b. Synchronizing the cellular signals are redundant GPSantennas 1002. Additionally, a VSAT or BGAN antenna 1004 and router 1003complete the hardware connectivity. The satellite router achievesconnectivity with the system by-way-of an available Ethernet port on theLAN/WAN routers 1001. Specialized real-time software running on theLAN/WAN routers 1001 constantly monitor the signal strength of each ofthe WAN connections to determine the most reliable signal. Also verifiedby the system 1000 is the response time, measured in network-layerlatency, of each WAN link to determine the connection best suited to bechosen as the primary link. A combination of the signal strength at thephysical layer and the lowest response time at the network layerdetermines the WAN connection best suited to transport the telemedicineapplications. SLAs may also be configured on the system to choose aconnection with the lowest application response time. Embeddedalgorithms also monitor connections for potential flapping, wherebyconnections continue to get chosen vs. other connections pathologicallybased on transient conditions preferring one connection over others.Flapping quickly leads to no data being transmitted/received. QoS, toensure specific applications receive preferential treatment over otherlower-priority applications, is governed in both the routers and at thetransport layer.

Referring to FIGS. 9A and 9B, a telemedicine cell wireless and satellitesystem is shown. Voice over IP (VOIP), a computer laptop or tablet withtelemedicine, other specialized software, and neuroimaging software, andother equipment connect in the ambulance or other moving vehicle orother site, e.g., clinic or hospital, to a LAN router with multiplemanaged Ethernet ports. The router routes data traffic to specific areasin the LAN and also aggregates multiple connections, including 3G, 4G,5G plus WiFi, plus LTE and satellite. The router can automaticallyswitch between cellular and satellite and other inputs by specificprogramming and firmware. Data can be aggregated or split. Within andoutside the ambulance or moving vehicle, the LAN router is connectedthrough its ports to specialized dual antennas, see FIG. 5, which cancommunicate directly with and switch between cell towers. These in turnprovide web connectivity and can connect to the operations center. TheLAN router can also have one or more connections through its Ethernetports to a VSAT modem, within the ambulance, which can then connectdirectly to a VSAT antenna or satellite terminal. Any satellite terminaldiscussed herein may include one or more antennas.

Referring to FIGS. 9A and 9B, the VSAT terminal may deliver power to theantenna (BUC and LNB) and is connected with a RF cable. Similarly, theLAN router can have, simultaneously, one or more connections to anL-Band satellite modem within or outside the ambulance. This modem canbe independent, connected by Ethernet or RF cable or incorporated into aSatellite antenna or terminal. An independent voice circuit can beconnected to the L-band modem for additional audio input. The satellitemodems are connected to antenna or satellite terminals which thenconnect with the satellites.

Referring to FIGS. 9A and 9B, three customer remote terminals can beinvolved. First, the Ku or Ka VSAT, manually or automatically, acquiresa signal that can be used and interfaces with the VSAT modem. The Ku andKa VSAT terminals are 0.6 meters to 3.6 meters. Second, the Ku or KaVSAT flat panel phased array terminal/terminal with size between 3-4 to30 cm. This is interfaced to VSAT modems. Third, L-Band Iridium orInmarsat BGAN portable manual or auto acquire that are mobile for movingvehicles can be interfaced with the L-Band modems. Each of the threeterminals can provide one-way simplex or two way duplex traffic and dataflow.

The satellites used in the exemplary embodiments herein include, but notlimited to, GEOs e.g., Inmarsat, SES, Intelsat, JSAT; MEOs, e.g., O3b,GPS; and LEOs, e.g., Iridium, Orbcomm. These satellites may have spotbeams, steerable beams, regional fixed beams, interplaying moving beams,and global fixed beams. The satellites can provide one-way or two-waydata flow to a satellite ground station or teleport. All traffic isprocessed at the stations in the hub and routed to specificdestinations, determined by IP packets and headers via multiple paths.These paths can include direct Internet, a VPN tunnel over the Internet,and a private fiber path to the operations center and mobile computerbased systems.

Referring to FIG. 10, the patient is evaluated within the ambulance orother moving vehicle or urgent care center or just outside thestationary vehicle with telemedicine involving a laptop computer withspecialized telemedicine, connectivity, and ultrasound software. Thetelemedicine system involves specialized camera. The ultrasoundexamination involves a special helmet and images are generated in thefield and at the operations center. The telemedicine, DICOM, and otherdata are transmitted via routers and specialized cellular wirelessantennas (according to some or all of the cellular communicationtechnologies discussed herein) as well as by specialized satelliteterminals/antennas (according to some or all of the satellitecommunication technologies discussed herein), that work together toprovide connectivity and quality of service. The data is transmitted tothrough satellite and cellular wireless through the cloud to theoperations center, that can view in real time all imaging andneurological examinations. At the point of care, the expert neurologistsand radiologists can perform their examination of the patient 24/7 bytheir computer, smart phone, or tablet. A consultation report is writtenthrough the operations center. Communication between the ambulance,ambulance medical director, potential destination hospital, stroke andhospital physicians that may receive the patient. Alerting is shown inFIG. 4.

In an exemplary embodiment, as shown in FIG. 1, the operations center120 is configured as a nexus for communication with multiple remotelylocated telemedicine systems (e.g., vehicle 102). The operations center120 may be implemented as a Virtual Desktop Infrastructure (VDI) in thecloud and can include a database 122, server application 124, alertingsystem 126, Digital Imaging and Communications in Medicine (DICOM)system 128, controller 130, and transceiver 132. A VDI clientapplication may be used on workstations, desktops, tablets, smartphonesand other mobile devices that run on Microsoft Windows, Linux, MacOS,Android, iOS, or other desktop or mobile operating systems, which wouldthen connect to the cloud-based, virtual servers. Transceiver 132 mayrepresent any modem and antenna package configured for cellular orsatellite communication. The operations center 120 can include aredundant power system to maintain operational power by switching from aprimary power source to a secondary power source in the event theprimary power source becomes unavailable.

The controller 130 is configured to control the overall operation of theoperations center 120, including controlling the operation of one ormore of the components of the operations center 120. The controller 130can include processor circuitry configured to perform the operations ofthe controller 130. The controller 130 can include memory to store dataand/or instructions.

The transceiver 132 is configured to transmit and/or receive wirelessand/or wired communications via one or more wireless and/or wiredtechnologies. The transceiver 132 can include processor circuitry thatis configured to transmit and/or receive wireless and/or wiredcommunications. The transceiver 132 can be configured to communicatewith one or more medical facilities 140, emergency vehicle control ordispatch centers 142, and/or medical physicians 144, as well as with oneor more emergency vehicles 102 and/or facilities 104 via the network 110(which may include satellite communication as discussed above) and theaccess point 108 and/or GNSS 106.

Those skilled in the relevant art(s) will recognize that the transceiver132 can also include (but is not limited to) a digital signal processer(DSP), modulator and/or demodulator, a digital-to-analog converter (DAC)and/or an analog-to-digital converter (ADC), an encoder/decoder (e.g.,encoders/decoders having convolution, tail-biting convolution, turbo,Viterbi, and/or Low Density Parity Check (LDPC) encoder/decoderfunctionality), a frequency converter (including mixers, localoscillators, and filters), Fast-Fourier Transform (FFT), precoder,and/or constellation mapper/de-mapper that can be utilized intransmitting and/or receiving of wireless communications.

The database 122 can be configured to store data, such as patientmedical records, including medical images, information regarding one ormore medical facilities 140, emergency vehicle control or dispatchcenters 142, physicians 144, and/or vehicles 102, and/or other data aswould be understood by those skilled in the relevant arts. The database122 can include processor circuitry configured to perform the operationsof the database 122.

The server application 124 can include one or more applications and/oroperating systems of the operations center 120. The applications caninclude one or more application that run to facilitate the functions ofthe operations center 120. The server application 124 can also host oneor more applications that can be provided to remote users, such as thevehicle 102, physicians, 144, dispatch centers 142, medical facilities140. The server application 124 can include memory that stores theapplication(s) and/or operating system(s). The server application 124can also include processor circuitry that can be configured to executethe application(s) and/or operating system(s).

The alerting system 126 is configured to generate and transmit one ormore alerts to one or more components within the telemedicine systemenvironment 100. For example, the alerting system 126 can generate analert in response to a vehicle 102 accepting a patient and/or thevehicle 102 completing a diagnostic test on the patient. The alertingsystem 126 can generate an alert that identifies the anticipated arrivaltime of the vehicle 102 to a hospital. In an exemplary embodiment, thealerting system 126 can include processor circuitry configured toperform the operations of the alerting system 126.

The Digital Imaging and Communications in Medicine (DICOM) system 128 isconfigured to handle, store, print, and/or otherwise process medicalimages. The DICOM system 128 can specific file formats and/or networkcommunications protocol to comply with the DICOM standard (i.e., NEMAstandard PS3, ISO standard 12052:200). The DICOM system 128 can includeprocessor circuitry configured to perform the operations of the DICOMsystem 128.

In operation, the operations center 120 can be configured to processdata through a central system of servers (e.g., server application 124)running an application that provides voice and video, textual data,imaging data, telemetry and tele-operation command communications. Thedata is routed to an available operations center specialist that istrained to operate the tele-operations and has radiology expertise toacquire usable image and Doppler data.

The operations center 120 may include of pool of radiologytele-operations specialists available to handle data from multiplepatients simultaneously. All data (e.g., time, date, patient ID,ambulance, location, images, radiologist or neurologist IDs, emergencyroom attending physician IDs, operations specialist IDs) surrounding atelemedicine system (e.g., vehicle 102) is collected in a database(e.g., database 122). The database provides internal records fortraceability as well as the data to be accessed as part of big dataanalytics. The operations center specialist will establishcommunications connections with a qualified diagnostician (e.g.,neurologist or radiologist) who will perform the actual assessment ofthe patient and will provide the consultation to the attendingphysician. Once the tele-operation specialist has acquired usableimages, the images will be uploaded to a medical image server where theywill be dispatched to the diagnostician and the attending physician, atwhich time the images also become part of the patient's electronicmedical records.

Diagnosticians (radiologists, neurologists) may be at an operationscenter facility or remote. An additional remote application can alsoallow for remote tele-operators. In this way, an external pool ofadditional diagnosticians and tele-operators may be on call as loaddemands. In addition to the command and telemetry interface for thetelemedicine systems, the remote tele-operator will also have fullcommunications with all diagnosticians, physicians, and ambulancepersonnel involved with the patient that is assigned to them by theoperations center 120.

In exemplary embodiments, the clinical examinations and/or themeasurements are collected while the patient is in transport in thevehicle 102, including the electronic health record of the patient withthe examination results (e.g., in text format and by audio/videocommunication) and the measurements are sent to an operations center 120and/or more neurological and/or radiological experts at one or moreremote locations, using advanced health information technologytechniques. The operations center 120 and/or neurological andradiological teams can analyze the measurements and/or one or morepatent images to determine whether a stroke or other injury has or isoccurring, and can provide instructions to the transport team of thevehicle 102. The operations center 120 can also communicate with one ormore emergency vehicle control or dispatch centers 142 and/or medicalfacilities 140 to determine the appropriate facility to route theemergency vehicle to.

In an exemplary embodiment, a textual electronic health record withexamination information and interpretation of other physiologicalmeasurements are provided to the ambulance personnel of the vehicle 102,the appropriate hospital to which the patient will be transported, andstroke and other personnel at that facility. This allows for the patientcan be transported to the appropriate facility and for preparations anddecisions to be made prior to the transport's arrival.

Upon arrival at the appropriate facility (e.g., hospital or emergencyroom), warranted and appropriate medical (e.g., stroke) diagnostics andtreatments can begin immediately, thus saving valuable time. Therapy forthe patients can be selected and increase the positive outcomes,including stroke reversal and reduced stroke severity, as well asreducing mortality. In assessing stroke, identifying abnormalities orreduced blood flow in neck or brain blood vessels are important becauseof the associated urgency with addressing these conditions.

FIG. 2 illustrates a telemedicine system 200 according to an exemplaryaspect of the present disclosure. The telemedicine system 200 can beincluded in one or more vehicles 102. In an exemplary embodiment, thetelemedicine system 200 includes a controller 205 connected to a networkrouter 220 supporting one or more communication transceivers, such astransceiver 225 and/or GNSS transceiver 240. The transceiver 225 can beconfigured to (wirelessly and/or via a wired connection) transmit and/orreceive communications conforming to one or more cellular (e.g., LTE)and/or non-cellular (e.g., WiFi, satellite) protocols via antenna 230.The transceiver 225 can be configured to transmit and/or receive GNSScommunications via antenna 245. Telemedicine system 200 can include aredundant power system to maintain operational power by switching from aprimary power source to a secondary power source in the event theprimary power source becomes unavailable. As discussed above,telemedicine system 200 can include any aspect of the telemedicinecommunication platform. Antenna 230 may be configured for communicationover any of the above-described satellite systems.

The telemedicine system 200 can include one or more imaging modalities250, one or more imaging device 225, one or more input/output (I/O)devices 260, one or more audio I/O devices 265, one or more displays270, and one or more medical instruments 275. These components can beconnected to the controller 205.

The controller 205 can include processor circuitry 210 and memory 215.The processor circuity 210 can be configured to control the overalloperation of the telemedicine system 200, such as the operation of oneor more components of the telemedicine system 200. The processorcircuitry 210 can be configured to carry out instructions to performarithmetical, logical, and/or input/output (I/O) operations of thetelemedicine system 200 and/or one or more components of thetelemedicine system 200.

In an exemplary embodiment, the processor circuitry 210 can beconfigured to control the operation of the transceiver 225 and/or theGNSS transceiver 240—including, for example (but not limited to),transmitting and/or receiving of wireless communications via thetransceiver 225 and/or 240, and/or perform one or more basebandprocessing functions (e.g., media access control (MAC),encoding/decoding, modulation/demodulation, data symbol mapping, errorcorrection, etc.).

The processor circuitry 210 can be configured to control the running ofone or more applications and/or operating systems; power management(e.g., battery control and monitoring); display settings and driving ofthe display 270; image processing of one or more images and/or videos tobe output by the display 270 and/or one or more images and/or videoscaptured by the camera 225, audio processing of audio captured/inputtedvia one or more audio I/O devices 265 (e.g., a microphone) and/or ofaudio outputted by one or more audio I/O devices 265 (e.g., speaker);image processing of one or more images and/or videos captured by one ormore of the imaging modalities 250; processing of medical measurementdata generated by one or more medical instruments 275; and/or routing ofcommunications via the network router 220.

In an exemplary aspect, the controller 205 can include one or moreelements of a protocol stack such as, a physical (PHY) layer, mediaaccess control (MAC), radio link control (RLC), packet data convergenceprotocol (PDCP), and/or radio resource control (RRC) elements.

The memory 215 that stores data and/or instructions, where when theinstructions are executed by the processor circuitry 210, controls theprocessor circuitry 215 to perform the functions described herein. Thememory 215 can be any well-known volatile and/or non-volatile memory,and can be non-removable, removable, or a combination of both. Thememory 215 can store one or more operating systems of the telemedicinesystem 200 and one or more applications operable to run on the operatingsystem(s). The memory 215 can also store one or more medical imagesassociated with the imaging modality 250, one or more medical records ofone or more corresponding patients.

The imaging device 255 is configured to capture image and/or video dataand provide the image/video data to the controller 205. The imagingdevice 255 can be, for example (but not limited to), a camera and/or avideo recorder. The imaging device 225 can be configured to processimage and/or video data captured by the imaging device 225 and providethe processed data to the controller 205, where the controller 205 mayperform additional processing in some embodiments. In an exemplaryembodiment, one or more of the imaging devices 255 are included in thevehicle 102 to provide images and/or video of the patient and/or theemergency personal in a multimedia telemedicine solution. The imagingdevices 225 can be mounted in the vehicle 102.

The I/O device 260 is configured to interface with the controller 205 asan input and/or output device of the telemedicine system 200. The I/Odevice 260 can include, for example (but not limited to), a keyboard,mouse, trackpad, smart pen, printer, scanner, and/or other input and/oroutput devices as would be understood by those skilled in the relevantarts.

The audio I/O device is configured to interface with the controller 205as an audio input device and/or audio output device of the telemedicinesystem 200. The audio I/O device 260 can include, for example (but notlimited to), a speaker configured to output audio, a microphoneconfigured to capture audio, and/or one or more other audio input and/oroutput devices as would be understood by one of ordinary skill in therelevant arts.

The display 270 is configured to display images and/or video data. Thedisplay 270 can be, for example (but not limited to), a computer monitoror other display device, projector, LCD display, LED display, OLEDdisplay, and/or one or more other display devices as would be understoodby one of ordinary skill in the relevant arts.

The medical instrument 275 is configured to measure or otherwise capturemedical information from a patient and/or output medical informationassociated with a patient to, for example (but not limited to), one ormore medical personnel. The medical instrument 275 can be, for example(but not limited to) an otoscope, a stethoscope, phonendoscope,sphygmomanometer, pulse monitor, thermometer, electrocardiograph (EKG,ECG), ultrasound device, and/or one or more other medical instruments aswould be understood by one of ordinary skill in the relevant arts.

The telemedicine system 200 and one or more of the components of thetelemedicine system environment 100 can be configured to utilize one ormore network optimization applications. In an exemplary embodiment, thecontroller 205 of the telemedicine system 200 can include a networkoptimization application configured to mask transient network outagesand/or reduced bandwidth from applications allowing the applications topause until the network connections are restored. By masking transientnetwork outages/reduced bandwidth, the application running andsupporting the telemedicine system 200 are unaware of connectivityissues (or the severity of an issue is reduced at the application level)to reduce and/or prevent the running applications from terminating orcrashing in response to a network outage. In this example, the networkoptimization application provides link resiliency to the communicationlinks of the telemedicine system environment 100. Controller 205 may beconfigured to switch communication networks to mask transient networkoutages, such as switching between cellular communication and satellitecommunication. Controller 205 may further switch between specific kindsof satellite communication (e.g., between BGAN and VSAT and/or 4Gcellular and 3G cellular) based on a detected level or network strength(e.g., signal strength optionally combined with data throughput).

The network optimization application can also be configured to provide aTransport Morphing Protocol (TMP). The TMP is an acknowledgement-baseduser datagram protocol (UDP) with built-in QoS (Quality of Service). TheTMP is configured to allow endpoints to automatically adjust data sendrate to reduce packet loss and minimize resent packets. The TMP allowsdata transfers and application performance to be maintained even ondegraded communication links and prevents application time-outs duringexcessive packet loss situations and/or high latency situations.

In an exemplary embodiment, the network optimization application cansupport one or more encryption technologies, such as Secure SocketsLayer (SSL) encryption. In an exemplary embodiment, the encryptiontechnologies can be used without requiring the installation of clientcertificates. Using these encryption technologies, the telemedicinesystem 200 can communicate with the components of the telemedicinesystem environment 100 while maintaining Health Insurance Portabilityand Accountability Act of 1996 (HIPAA) compliance.

In an exemplary embodiment, the network optimization application isCircadence's MVO 1200 Optimization Suite produced by CircadenceCorporation, but is not limited hereto.

In an exemplary embodiment, the network router 220 is configured toforward data packets between two or more networks, using, for example(but not limited to), one or more routing tables and/or routingpolicies. The network router 220 can be configured to interface with oneor more cellular networks (e.g., LTE, EVDO, HSPA+), one or morenon-cellular networks (e.g., WiFi 802.11), and/or one or more GNSSnetworks. In an exemplary embodiment, the network router 220 includesprocessor circuitry configured to perform the operations of the networkrouter 220.

For example, the network router 220 can be configured to route datapackets conforming to one or more cellular networks, including, forexample (but not limited to) Long-Term Evolution (LTE), EvolvedHigh-Speed Packet Access (HSPA+), Wideband Code Division Multiple Access(W-CDMA), CDMA2000, Time Division-Synchronous Code Division MultipleAccess (TD-SCDMA), Global System for Mobile Communications (GSM),General Packet Radio Service (GPRS), Enhanced Data Rates for GSMEvolution (EDGE), and Worldwide Interoperability for Microwave Access(WiMAX) (Institute of Electrical and Electronics Engineers (IEEE)802.16) to provide some examples. The network router 220 can beconfigured to route data packets conforming to one or more non-cellularnetworks, including, for example (but not limited to) one or more IEEE802.11 protocols (e.g., WiFi), Bluetooth, Near-field Communication (NFC)(ISO/IEC 18092), ZigBee (IEEE 802.15.4), and/or Radio-frequencyidentification (RFID), to provide some examples.

The network router 220 can be configured to route data packets using oneor more satellite communication technologies, including one of moreglobal navigation satellite systems (GNSS) protocols that include, forexample (but not limited to) Global Positioning System (GPS), theRussian Global Navigation Satellite System (GLONASS), the European UnionGalileo positioning system (GALILEO), the Japanese Quasi-ZenithSatellite System (QZSS), the Chinese BeiDou navigation system, theIndian Regional Navigational Satellite System (IRNSS), and/or anotherGNSS protocol as would be understood by those skilled in the art.

The network router 220 can be configured to route data packets via oneor more wired connections, such as Ethernet connections, fiber opticconnections, and/or one or more other wired connections as would beunderstood by those skilled in the art.

In an exemplary embodiment, the network router 220 can include one ormore embedded 4G/LTE broadband radio interfaces for true high speedconnectivity to on-board applications, Dual 4G/LTE modem and SIM supportfor automatic failsafe backup through an alternative cellular broadbandnetwork, a robust mechanical and electrical design optimized forunattended vehicle cabinet installations, a WiFi 802.11 interface(including 802.11n, 802.11ac) with configurable operation mode (AccessPoint or Client), a multi-port Ethernet switch (e.g., 4-port, 8-port,etc.), a global navigation system, Hardware-based data encryption,software-based data encryption, Virtual Private Network (VPN)applications, and/or firewall features. In an exemplary embodiment, thenetwork router 220 is Teldat LTE H1-Auto+ Router made by TELDAT USA, butis not limited hereto.

The transceiver 225 is configured to interface with the network router220 and to transmit and/or receive wireless and/or wired communicationsvia one or more wireless and/or wired technologies via antenna 230. Thetransceiver 225 can include processor circuitry that is configured totransmit and/or receive wireless and/or wired communications. Thetransceiver 225 can be configured to communicate with one or moremedical facilities 140, emergency vehicle control or dispatch centers142, and/or medical physicians 144, as well as with one or more otheremergency vehicles 102 and/or facilities 104 via the network 110 and theaccess point 108.

The GNSS transceiver 240 is configured to interface with the networkrouter 220 and to wirelessly transmit and/or receive GNNS communicationsvia antenna 245. The GNSS transceiver 240 can include processorcircuitry that is configured to wirelessly transmit and/or receive theGNSS communications. The transceiver 240 can be configured tocommunicate with one or more orbiting satellites. By communicating withone or more satellites, the GNSS transceiver 240 can communication withone or more medical facilities 140, emergency vehicle control ordispatch centers 142, and/or medical physicians 144, as well as with oneor more other emergency vehicles 102 and/or facilities 104 via thenetwork 110 and the global navigation satellite system (GNSS) 106. TheGNSS antenna 245 can be configured to transmit and/or receive GNSScommunication signals sent to/received from one or more orbitingsatellites.

Those skilled in the relevant art(s) will recognize that the transceiver225 and/or the GNSS transceiver 240 can also include (but is not limitedto) a digital signal processer (DSP), modulator and/or demodulator, adigital-to-analog converter (DAC) and/or an analog-to-digital converter(ADC), an encoder/decoder (e.g., encoders/decoders having convolution,tail-biting convolution, turbo, Viterbi, and/or Low Density Parity Check(LDPC) encoder/decoder functionality), a frequency converter (includingmixers, local oscillators, and filters), Fast-Fourier Transform (FFT),precoder, and/or constellation mapper/de-mapper that can be utilized intransmitting and/or receiving of wireless communications.

With continued reference to FIG. 2 and with reference to FIGS. 5A-5I,the antenna 230 can be configured to wirelessly transmit and/or receivecommunications via one or more wireless technologies. In an exemplaryembodiment, the antenna 230 includes two di-pole antennas that providecontinuous Physical layer signaling to mobile endpoints. In an exemplaryembodiment, the antenna 230 is a dual di-pole antenna configured for oneor more cellular and/or non-cellular communication protocols. Forexample, antenna 230 can be a 4G LTE di-pole antenna in smallform-factor radome that enables signal transmission and reception withhorizontal and vertical polarities. This configuration allows foruninterrupted signal reception in a moving emergency vehicle, includingat speeds over 80 Mph. The antenna 230 is configured to maintain signalconnection as the vehicle 102 moves between multiple cellular towers. Inan exemplary embodiment, the antenna 230 is a multiple-input andmultiple-output (MIMO) antenna. The antenna 230 can be an antenna arraythat includes two or more antenna elements.

In an exemplary embodiment, antenna 230 is a Venti CORE™ antennasolution that is a 2-port MIMO antenna incorporating one or morevertically polarized antennas and one or more true horizontallypolarized antennas, but is not limited thereto. In an exemplaryembodiment, the antenna 230 includes a single vertically polarizedantenna and a single horizontally polarized antenna. In this example,the use of both a true horizontal and a vertical antenna in a MIMOantenna configuration that utilizes polarization diversity to deliverhigher data rate throughput and greater coverage.

In an exemplary embodiment, antenna 230 supports all carrier frequencybands covering 698-960, 1,710-2,700 MHz on both ports, but is notlimited to these frequency bands. The isolation of the two antennas isgreater than 20 dB at every frequency. Typical VSWR is 1.3:1 (vertical)and 1.5:1 (Horizontal). The radome can be made of, for example (but notlimited to), UV-ABS plastic and is designed for roof mounting onambulances, but it not limited thereto. In an exemplary embodiment, theantenna dimensions are 6.53″W×15.55″L×5.62″ H, but are not limitedthereto.

FIGS. 5A-5K illustrate exemplary radome enclosures and antenna systemsaccording to exemplary embodiments of the present disclosure. The radomeenclosures can be configured to house di-pole antenna elements (e.g.,two elements) of the antenna 230. FIG. 5A shows a left-side view; FIG.5B shows a bottom view; FIG. 5C shows a perspective view taken from thebottom, left side thereof; FIG. 5D shows a perspective view taken fromthe top, left side thereof; FIG. 5E shows an internal side view thatillustrates an example arrangement of the antenna elements; FIG. 5Fshows right-side view; FIG. 5G shows two cross-sectional views (takenalong X and Y) and a right-side view that shows the locations of the Xand Y sections; FIG. 5H shows three views: a bottom view, a perspectiveview taken from the bottom, right, front side thereof, and a perspectiveview taken from the bottom, right, back side thereof; FIG. 5I shows sixviews: a right-side view, a left-side view, a back view, a front view, atop view, and a perspective view taken from the top left, front sidethereof. FIG. 5J illustrates an interior view of a radome housing anantenna system that is mounted to an emergency vehicle; and FIG. 5Kshows two views: a bottom support member having two di-pole antennaelements mounted thereto, and a perspective view of the bottom supportmember having a radome placed thereon that is taken generally from thebottom, back left-side thereof

With reference to FIGS. 5A-5E, 5J and 5K, the antenna 230 includes twodi-pole antenna elements, one disposed in the radome near the back endof the radome and the other closer to the front of the radome. The firstantenna element of the antenna 230 located at the back end can includevertically-arranged antenna radiator planes. In an exemplary embodiment,the radiators can be configured in a plus (+) shaped arrangement whenviewed from the top of the arrangement. In an exemplary embodiment, thefirst antenna element can be configured as a vertically polarizedantenna. The second antenna element of the antenna 230 located near thefront end of the radome can include one or more horizontally-arrangedantenna radiator planes. For example, the second antenna element caninclude two more horizontally-arranged antenna radiator planes that arearranged in the same horizontal plane. In an exemplary embodiment, thesecond antenna element can be configured as a horizontally polarizedantenna. In an exemplary embodiment, the antenna 230 is externallydisposed on the vehicle 102 and connected to the transceiver 230 locatedwithin the interior of the vehicle 102. The

Returning to FIG. 2, the imaging modality 250 is configured to generateone or more imaging modalities of a patient. The imaging modalities caninclude, for example (but not limited to), ultrasound images such as,carotid, transcranial Doppler (TCD), and/or Transcranial Color CodedDoppler (TCCD), photoacoustic spectroscopy, and phased array ultrasound.The Doppler imaging can include both two-dimensional (2D) andthree-dimensional (3D) imaging. The imaging modalities are limitedthereto and can include, for example (but not limited to), computedtomography (CT) imaging, positron emission tomography (PET) imaging,single-photon emission computed tomography (SPECT), X-ray imaging,magnetic resonance imaging (MRI), nuclear magnetic resonance imaging(NMRI), magnetic resonance tomography (MRT), and/or another imagingtechnology as would be understood by those skilled in the relevant arts.In an exemplary embodiment, the imaging modality 250 is a helmet andcollar device configured to generate medical images of blood vessels ofthe brain and neck region of the patient. In an exemplary embodiment,the telemedicine system 200 can use raman spectroscopy and/or othermolecular diagnostic techniques in addition to, or alternatively to,these imaging modalities. In an exemplary embodiment, molecular analysiscan be performed on, for example (but not limited to), serum, plasma,cells, and/or other tissue, but is not limited hereto. Exemplary imagingmodalities and other diagnostic technologies are described in moredetail in the “Exemplary Imaging Modalities and Diagnostic Technologies”section below.

The imaging modality 250 can be configured to generate 2D and 3D CarotidDoppler images, Transcranial Doppler images, and/or Interventionalangiography. The imaging modality 250 can be configured to perform brainand neck vessel angiography to visualize brain and neck artery anatomywith contrast. Using the generated images, it can be determined if apatient should receive an intra-arterial clot buster solution or if aclot retrieval or other surgical procedures to physical remove clot fromneck (carotid) arteries should be performed. For example, thesetechniques can facilitate delivery of clot buster to blocked arteries orthe unblocking of arteries with intra-artery clot buster or clotretrieval with or without stenting. The images can also be used toverify a successful removal of the obstruction. Oxygenation efficacy ofdamaged and surrounding tissue can be assessed with carotid and/ortranscranial Doppler, phased array, and photoacoustic spectroscopy.

The imaging modality 250 can provide real time analysis of blood flowvelocity and flow direction and other neck and brain blood flow measuresin a pre-hospital situation as the patient is being transported to amedical facility in the vehicle 102. For example, carotid Doppler andtranscranial Doppler and phased array ultrasound can be used to providethis analysis.

In exemplary embodiments, a potential stroke can be identified byproviding brain insight data to the medical personnel in advance of thepatient's arrival. The telemedicine system 200 can provide a depictionof, for example (but not limited to), the middle cerebral arteries,carotid arteries, and basilar Artery. Tomography of oxygenation invarious (e.g., three) regions of middle cerebral artery territory andvarious (e.g., two) regions of basilar artery can also be performed.

FIGS. 3A & 3B illustrate a telemedicine system 300 according to anexemplary embodiment of the present disclosure. The system 300 shown inFIG. 3 illustrates the interaction of components of a telemedicinesystem, the operations performed by the components, and the interactionsbetween the various components. In the telemedicine system 300, apatient with a stroke, a traumatic brain injury (TBI), otherneurological disorder, or other clinical disorder presents in anemergent situation in a civilian or military context and is evaluatedand transported in an ambulance, seen and then transported ifappropriate from an urgent care clinic, helicopter, plane, or othermoving vehicle. At the point of care and during transport, real timeneurological examination with a NIH Stroke Scale is performed bytelemedicine evaluation as shown in FIG. 3 using the telemedicinesystems illustrated in FIGS. 1-2 that include optimized connectivity andaudio video quality (Data transmission optimization), in particular inrural and urban areas or in forward military positions in conjunctionwith wireless and cellular towers and with satellites in somecircumstances. Large head vessels, particularly the basilar artery andmiddle cerebral artery can be imaged with, for example (but not limitedto), transcranial Doppler or transcranial color-coded Doppler. The largeneck vessels, the carotid arteries are evaluated by, for example (butnot limited to), 2D and 3D carotid Doppler. The neurological andradiological examination is performed by experts and the vascularexamination is facilitated by a helmet with probes, which is easy toapply. The data optimization is fostered by software and hardware,including routers and antennas, in conjunction with cellular towers,wireless access points and/or satellite communications. Data istransmitted to an operation center which directly involves theneurologists and neurologists where a diagnosis of large vesselobstruction or stenosis might be suggested, or another disorder, such asa brain hemorrhage or brain trauma with vessel spasm or vessel tearingor other neurological disorder. The operations center staff and theconsulting neurologists and radiologists can communicate directly withthe ambulance, the ambulance dispatch, the ambulance medical director orother facility personnel in real time as well as hospital personnel,including emergency department physicians, neurologists, and to otherphysicians. A decision is made where to transport and what to prepare atthe institution by the receiving hospital. If a stroke, clot buster maybe warranted or clot retrieval may be needed. The operations center alsocan also develop data within an electronic health record that may betransmitted to the hospitals electronic health record system or by fax.Data storage and analysis sub-acutely can also occur from the operationscenter. Alerting from the ambulance on pickup to the operations centerlead to triggering of alerting to tele-neurologist/tele-radiologist, whothen can alert back to the operations center when their evaluation iscompleted. This is followed by alerting to the hospital, hospitalphysicians, ambulance, and/or ambulance dispatch. The operations centerperforms a critical role in coordinating all efforts for careprehospitally during delivery to the appropriate hospital andspecialists, where further evaluation and therapy can be delivered, whenwarranted. Exemplary embodiments herein are directed to systems of carepredicated on telemedicine and physiological and neurological evaluationthat may optimize the quality and process of care with initiation ofearly, safe, and appropriate diagnosis and therapy that may improveprognosis and prevent death.

In an exemplary embodiment, upon the presentation of stroke or otherbrain injury symptoms in a person, an emergency vehicle (e.g.,ambulance, plane, helicopter, etc.) can be dispatched to the person. Orthe person can be taken to an urgent care facility by other means.

In an ambulance scenario, ambulance personnel can evaluate a stroke inthe field or on the ambulance's way to a medical facility using atelemedicine system such as the system 200. Multimedia (audio, video)information of a neurological exam to an operations center.Additionally, one or more imaging modalities can be used to capturemedical images that can be transmitted to the operations center. Theoperations center can communicate with one or more medical facilities,including one or more medical professional either at the facility orremotely located. Based on the examination results, the operationscenter can direct the emergency vehicle to an appropriate facility aswell as instruct the facility prepare for the arrival of the patient.

The ambulance can be outfitted with a telemedicine system configured tosend valuable telemetry to the medical facility ahead of the patient'sarrival. A neurological examination using, for example (but not limitedto), the NIH stroke scale would be performed. A Transcranial Doppler ofBilateral Middle Cerebral Arteries and Carotid Arteries and then BasilarArtery can be performed. These arteries are the large arteries that cancause the most severe stroke and that would be amenable to intravenousor intra-arterial therapy. In exemplary embodiments, depending on thelength of the ambulance ride, the neurological examination andultrasound examinations could be repeated or could be continuous toprovide ongoing data about the patient during transport.

FIG. 4 illustrates a telemedicine system 400 according to an exemplaryembodiment of the present disclosure. The system 400 shown in FIG. 4illustrates the interaction of components of a telemedicine system, theoperations performed by the components, and the interactions between thevarious components, including the interactions between software andhardware components, as well as the flow of information and data. Withreference to FIG. 4, alerts and hardware and/or software are illustratedfor the ambulance telemedicine evaluation. The ambulance and theambulance paramedics and crew pick up the patient and an ambulanceelectronic health record is begun (1). At the same time (2), an alert issent to the operations center and a patient case is opened. An alert (3)is sent to the expert teleneurologists, telestroke specialists, andteleneuroradiologists that a case has begun and evaluation of thepatient by telemedicine and ultrasound begins immediately by thesephysicians in the ambulance or other moving vehicle (4). A consultationis generated by these physicians using a template at the operationscenter (4). The operations center is alerted as the examination iscompleted (5). The operations center at (6) sends an alert and starts atelemedicine communication with the operations center, the evaluatingexpert neurologists and radiologist, Ambulance, Ambulance MedicalDirector, the potential receiving hospital, i.e. primary orcomprehensive stroke center, and the formal physician consultation issent to the hospital and stroke center. The ambulance Medical director,hospital, and stroke neurologists then make decisions at to destinationfor patient delivery, preparation and studies to be done on patient atreceiving hospital, including special and personnel needed for potentialclot buster and endovascular clot retrieval procedures. The telemedicineand ultrasound and other evaluations to be determined are sent to an AVarchive (7) and all notes, alerts, measures, accounting and other datafor the specific patient encounter are sent to the AV archive (7). Allinitial data from the encounter is sent to a secure data warehouse and abackup warehouse (8). Data is available for big data analytics from thisdata warehouse in collaboration with the operations center and thetelemedicine group.

Data from the destination hospitals, including neurological examinationand imaging examinations, therapy, hospital records, and measures, i.e.time to therapy, time to diagnosis, success measures, acute and subacuteoutcome measures are also sent to the operations center and datawarehouse (9).

FIG. 6 illustrates an example emergency response sequence 600. Upon thepresentation of stroke or other brain injury symptoms, emergencyservices can be contacted (e.g., a call to 911), which dispatches anemergency vehicle and personnel to the person. The emergency vehicle cantransport the patient to a stroke center or hospital where medicalimages can be taken, including vessel imaging, and appropriate medicaltreatments can be performed. In this response sequence, substantial timehas passed before the patient receives the appropriate treatments, suchas treatment for stroke. This delay in treatment can significantlyreduce recovery while increasing long-lasting or permanent strokeeffects and mortality rates. FIG. 6 illustrates an example emergencyresponse sequence 600 for, for example (but not limited to), stroke (butis not limited to stroke treatments). The patient develops neurologicalsymptoms that might be consistent with a stroke and a 911 call is made.An ambulance is dispatched and the crew does an evaluation. Depending ontheir evaluation and that of dispatch center, the patient may be sent toa primary stroke center (shown) or a stroke ready center or in somecases to a comprehensive stroke center. In rural settings, this may be anon-stroke center or a stroke ready hospital. Larger urban centers mayhave preponderance of primary stroke centers and one or morecomprehensive stroke centers. Time for transport to the hospital willdepend on the time for an ambulance to arrive, evaluation at the siteand clinical care, and then transport to a hospital. A medical record isgenerated in the ambulance that may be on paper or electronic. A certaintime range is illustrated. In a typical situation, the patient arrivesto a stroke ready or primary stroke center and the hospital is alertedabout a potential stroke. Hospitals may have a stroke alert,mobilization of a stroke team, and as the patient arrives the protocolvaries even though there is a national standard for stroke protocols.The emergency department may not be optimized for strokes and usually aninitial examination by the emergency physician is done, a neurologist iscalled, and a CT scan is done. Neurologists may not be available and mayhave variable time before they can arrive for examination. Radiologistsskilled in stroke evaluations may not be available. Alternatively, aTele-stroke cart or robot in the emergency department may allow distantcommunication and real time with a neurologist. A neurologicalexamination with a formal NIH Stroke Scale is performed, but this may ormay not involve a stroke neurologist. A decision after consideringexclusions and inclusions, the time of initial stroke onset, the CTscan, and neurological examination is then made to give or not give tPA.This process is variable across different primary and stroke readyhospitals, as illustrated. The Golden Hour delivery from symptom onsetto tPA administration may be achieved and carries with a betterprognosis. The longer the delay of clot buster in warranted and safesituations, the poorer the prognosis with a range up to 4.5 hours. Insome stroke ready and primary stroke centers, the ability to imagevessels by CT angiography or MR angiography in combination with theneurological examination and CT scan may suggest a large vessel stroke.The patient can then be transferred to a comprehensive stroke center,where there is the capacity to perform clot retrieval with stentretrievers or other devices in combination with cerebral angiography.The time delay is significant in these cases where the patient firstgoes to a primary stroke center and then to a comprehensive strokecenter. However, clot retrieval can occur, depending on the case andcenter up to 6 to 8 hours after stroke onset or up to 12 hours afterstroke onset. Longer lengths of time are not ideal for tPA or for clotretrieval as more brain is at risk for death. Again, time from strokeonset to therapy is critical for prognosis. In some cases, the patientmay be delivered to a comprehensive stroke center, that has 24/7neurology coverage, imaging modalities, and both tPA and clot retrievalavailable. The time and prognosis is better in this primary transport toa comprehensive stroke center.

FIG. 7A illustrates an emergency response 700 of brain injuries andmedical treatments in response to the presentation of brain injurysymptoms using a telemedicine system according to exemplary embodiments.An alternative to the general protocol in FIG. 6 is to performpre-hospital neurological evaluation and vascular evaluation of thelarge vessels in the ambulance or other moving vehicle. As illustratedin the present disclosure, quality real time, neurological examinationincluding a NIH Stroke Scale, is performed by an expert vascularneurologist. Data on the large vessels for stenosis or obstruction isobtained with carotid and transcranial Doppler in real time. If thesestudies and neurological examination suggests a large vessel stroke, thepatient can be transferred directly to a comprehensive stroke for tPA,angiography, and clot retrieval of brain vessel obstructions or stentingor endarterectomy of neck vessel stenosis or obstruction. The time isshortened to definitive therapy and the ED and appropriate physiciansand other services are alerted and prepared for the patient, whetherthat involves CT, other vessel imaging modalities, or catheterizationfor clot retrieval or surgery to remove neck clots or obstruction. Thechange of accurate diagnosis and improved prognosis as well as reversalis enhanced by changing the process and logistics for the patient. Ifthe patient can only go to a primary stroke center, similar benefits areseen with earlier use of tPA clot buster and then transfer can occur, ifwarranted.

Upon the presentation of stroke or other brain injury symptoms,emergency services can be contacted (e.g., a call to 911), whichdispatches an emergency vehicle and personnel to the person. With anemergency vehicle (e.g., ambulance, plane, helicopter, etc.) thatincludes a telemedicine system such as the system 200, a neurologicalexam can be performed in the emergency vehicle and correspondingmultimedia (audio, video) information of the exam is transmitted to anoperations center, as well as one or more medical facilities.Additionally, one or more imaging modalities can be used to capturemedical images that can be transmitted to the operations center and/ormedical facilities. Upon arrival at the medical facility, appropriatemedical treatments can be performed (e.g., intravenous or intra-arterialtherapy). FIG. 7B illustrates an emergency response 702 using atelemedicine system according to exemplary embodiments. As shown, aneurological exam can be performed in the emergency vehicle andcorresponding multimedia (audio, video) information of the exam as wellas medical images from one or more medical imaging modalities (e.g.,helmet and neck imaging device) are transmitted to an operations center,as well as one or more medical facilities. FIG. 7B is expanded to showTelestroke evaluation by neurology and radiology (Panel C) with cellularand/or satellite and the large vessel examination with special apparatusto allow easy application of probes for looking at the neck and headvessels with ultrasound (Panel A). A typical 3D carotid Doppler pictureof the carotid artery is demonstrated (Panel B) and it is evident thatobstruction can be observed if present. This can be obtained within 30seconds per carotid artery. The expert neurological and radiologicalexamination of the Dopplers is illustrated distally in real time. Largevessel strokes can result from obstruction or stenosis in the basilarartery (D1), the carotid artery (D2), or the middle cerebral artery(D3). These large vessel strokes have the potential with moresignificant injury and disability. Imaging at a comprehensive stroke canshow obstruction of the middle cerebral artery (Panel E) and with clotretrieval with use of retrieval devices, such as a stent retriever,revascularization is demonstrated with re-perfusion of areas that werenot getting blood flow or oxygen. The exemplary embodiments aredeveloped to promote this type of result.

By using telemedicine systems according to the exemplary embodimentsdescribed with increase network connectivity, treatment success ratesperformed at trauma centers for brain injuries such as stroke aresignificantly increased.

Exemplary Imaging Modalities and Diagnostic Technologies

The following discussion includes example imaging modalities and otherdiagnostic technologies that can be implemented in the telemedicinesystems of the exemplary embodiments of the present disclosure.

2D and 3D Carotid Doppler, Transcranial Doppler and InterventionalAngiography

Embodiments described herein use direct interventional therapy, whichinitially can involve brain and neck catheter-based angiography. Brainand neck vessel angiography, which visualizes brain and neck arteryanatomy precisely with contrast, is warranted in those patientsappropriately selected to get intra-arterial clot buster or clotretrieval or in surgical procedures to physical remove clot from neck(carotid) arteries. These techniques are generally the standard in brainand neck vessel definition, with particular relevance to obstruction andcollateral blood flow. These techniques provide the platform fordelivery of clot buster to blocked arteries or unblocking of thosearteries with intra-artery clot buster or clot retrieval with or withoutstenting. These techniques also provide information after theobstruction clearing attempts at successful opening of the blocked orobstructed vessels. These angiography techniques only provide ananatomical picture but no information on tissue efficacy of potentiallydamaged tissue before, during, or after the procedure. Oxygenationefficacy of damaged and surrounding tissue at these times cannot beassessed with angiography but could be intravascularly assessed withcarotid and/or transcranial Doppler, phased array, and photoacousticspectroscopy.

Additionally, in exemplary embodiments, real time analysis of blood flowvelocity and flow direction and other neck and brain blood flow measuresis not available pre-hospital or in the Emergency Department. These canbe provided with carotid Doppler and transcranial Doppler and phasedarray ultrasound. Also, known techniques, except transcranial Doppler,are unable to detect and characterize brain or neck artery emboli,define vessel plaque characteristics, and measure vessel-wall thickness(carotid Doppler with intimal thickness).

In another embodiment, a method for allowing an ambulance crew or EMTs(Emergency Medical Technicians) to evaluate a stroke out in the field oron the ambulance's way to the E.R., (it should be appreciated that ER,emergency room,) the ambulance would be outfitted with the presentinvention which would send valuable telemetry to the E.R. ahead of thepatient's arrival. The steps would include dispatching an ambulance andEMT to the patient. A neurological examination with a NIH stroke scalewould be performed. A Transcranial Doppler of Bilateral Middle CerebralArteries and Carotid Arteries and then Basilar Artery would be performed(These are the large arteries that can cause the most severe stroke andthat would be amenable to intravenous or intra-arterial therapy). In anexemplary embodiment, depending on the length of the ambulance ride, theneurological examination and ultrasound examinations could be repeatedor could be continuous to provide ongoing data about the patient duringtransport.

Brain and Neck Ultrasound Examination

Transcranial Doppler and Carotid Doppler provide for real time analysisof brain and neck blood flow that compliment anatomical representationsof brain and neck arterial anatomical imaging, i.e. CT and MRangiography of head and neck. A piezoelectric crystal emits ultrasoundpulses and listens for reflected echoes (sound waves). The reflectedechoes may provide time of flight, intensity, or frequency data of thereflected versus the transmitted wave. Velocity of blood flow is basedon the calculated frequency shift of reflected waves.

Both transcranial and carotid Doppler are performed in a standardsequence that involves placement upon sites to insonate the vessels,listening for the sound of blood flow that may reflect on normal flow orobstructed flow, and determination of anatomical vessel characteristics(carotid Doppler), spectral analysis with blood flow velocity and pulsewave determination (carotid and transcranial Doppler), adventitialembolic signals (transcranial Doppler), power m mode (transcranialDoppler) and comparison of anatomical and blood flow velocity and waveanatomy with known, established, and normal standards to determinenormal versus abnormal, including determination of abnormal vessels withdegree of stenosis and obstruction. Low or elevated blood flow mayreflect on local pathology of the neck or brain blood vessels or theefficacy of blood flow from the heart, i.e. cardiogenic shock, cardiacvalve disorders, or sepsis. Rapid and real time transcranial Doppler andcarotid Doppler can identify critical stenosis or obstruction inspecific neck and brain blood vessels that will provide information forcorrect hospital transport, hospital preparation for strokeintervention, appropriate treatment selection, and time savings to savebrain cells.

In exemplary embodiments, Transcranial Doppler can be used for othermeasures that reflect on brain intracranial pressure and vesselreactivity that can reflect on conditions of increased brain pressure,related to traumatic brain injury, brain swelling from many causes, orlarge stroke with brain swelling.

Carotid Doppler

Vascular duplex ultrasound of the carotid Doppler involves 2 ultrasoundcomponents, B-mode Gray Scale (2-D imaging) and Doppler imagingincluding flow measurement, color Doppler and spectral Doppler withblood flow velocity measurement. In an exemplary embodiment, carotidDoppler will include the above elements and will be recorded with apreviously validated (NASA Space Simulator) carotid Doppler system andtransducers affixed to the bilateral carotid arteries. The transducerwill be a standard 4 cm or larger convex as opposed to lineartransducer. A single sampling point will be used as opposed to multiplesampling points for proximal, middle, and distal carotid arteries. Rawimaging data will be sent wirelessly to the data/operations center,processed there, and analyzed similar to the transcranial Dopplerultrasound. The carotid Doppler probes will be used to evaluate thecarotid arteries and the neck vertebral arteries. The carotid Dopplerprobe will be incorporated into the neck portion of the helmet (see,e.g., FIGS. 7A, 7B (Panels A and B) & 10). The internal carotid arteryis particularly relevant for stroke.

B mode or gray scale imaging can look at the carotid artery andassociated anatomical vessel and other structures in transverse orlongitudinal plane. B mode is useful for defining the internal carotidartery wall and characterizing, localizing and defining extent and sizeof low or high echo structures, including atherosclerotic plaque, thatmay be obstructing the vessel, i.e. internal carotid artery. Plaqueusually results from aging change and pieces of plaque may dissociateand lead to emboli sent distally. Carotid artery tearing, plaqueobstruction, or emboli from plaque or carotid artery spasm, bleedinginto the carotid wall, can all lead to stroke. Information related tothese causes can be derived from B mode imaging.

Complimentary to B mode imaging, color flow Doppler can reveal bloodflow direction and mean velocity of flow and is very useful for imagingstenosis or obstruction and the site within the vessel. At variouslevels of the carotid artery, the peak and mean flow velocities,resistance, and actual arterial wave on spectral imaging providesquantitative numbers for determination of obstruction and stenosis ofthe internal carotid artery. All elements of the carotid Dopplerexamination as well as information on the vertebral arteries in the neckcan be rapidly accessed and used for rapid evaluation of stroke, itscause, and potential intervention. Other arteries can be assessed in theneck as part of the internal carotid artery examination.

3D Carotid Doppler

In another embodiment, multiple 2D carotid images can be rapidlyobtained through a carotid ultrasound device and processed andreconstructed into a 3D or 3 dimensional image of the carotid artery.The latter incorporates B mode and color flow Doppler. Rapididentification of stenosis and obstruction can be demonstrated withcombined individual 2D internal carotid Doppler and separate 3D carotidDoppler.

Transcranial Doppler

Transcranial Doppler (TCD) is a test that measures the velocity of bloodflow through the brain's blood vessels, usually the mean blood flowvelocity. Blood flow velocity is recorded by emitting a high-pitchedsound wave from the ultrasound probe, which then bounces off of variousmaterials to be measured by the same probe. A specific frequency is used(usually close to 2 MHz), and the speed of the blood in relation to theprobe causes a phase shift, wherein the frequency is increased ordecreased. This frequency change directly correlates with the speed ofthe blood, which is then recorded electronically for later analysis.Normally a range of depths and angles must be measured to ascertain thecorrect velocities. For transcranial Doppler, the site of insonationdetermines the potential vessels to be sampled, i.e. pre-temporal forexample is for middle cerebral arteries or anterior cerebral arteries.This technique is an indirect measure and depth of insonation by power mmode is directly related to the position on a specific artery.

Because the bones of the skull block the transmission of ultrasound,regions with thinner walls insonation windows can be used for analyzing.For this reason, recording is performed in the temporal region above thecheekbone/zygomatic arch, through the eyes, below the jaw, and from theback of the head. Patient age, gender, race and other factors affectbone thickness, making some examinations more difficult or evenimpossible. Most can still be performed to obtain acceptable responses,sometimes requiring using alternate sites from which to view thevessels.

Transcranial Doppler is a real time technique that is sensitive andspecific for blood flow velocity in multiple medium and large bloodvessels of the brain over a broad range of velocities, able to determinebrain blood vessel resistance, useful in determining collateral flowpresence and efficacy and cerebral atherosclerosis, able to compareblood flow in blood vessels in comparison from one side of the brain tothe other, is the only technique available for brain emboli detection,and can reliably predict vessel obstruction. Transcranial Doppler imagescan give specific artery and within artery information on mean flowvelocity, flow direction, and obstruction and stenosis. Wave analysis onspectral flow is also useful in defining site of stenosis or obstructionas well as efficacy of blood flow. Transcranial Doppler analysis followsa sequential analysis of the ophthalmic vessels, the vessels in theanterior circulation, noted pre-temporally, and the posteriorcirculation at the back of the head, with continuous listening forbruits and atherosclerosis and also emboli followed by prolonged embolidetection. Specific abnormalities in the waveform and also specificvelocities may be associated with obstruction and stenosis when comparedto normal age related standards for specific vessels.

Eye patch transcranial Doppler probes may be applied to the eyelids tosample the ophthalmic arteries bilaterally and transcranial probes willbe used in the pre- temporal region to evaluate the middle and anteriorcerebral arteries and other arteries bilaterally and in the back of thehead to evaluate the basilar artery and vertebral arteries and otherarteries (see, e.g., PCT Application No. PCT/US2013/067713, U.S. patentapplication Ser. No. 14/674,411; (C) U.S. patent application Ser. No.14/070,264; (D) U.S. patent application Ser. No. 14/084,039; (E) U.S.Provisional Application No. 61/720,992; (F) U.S. Provisional ApplicationNo. 61/794,618; and (G) U.S. Provisional Application No. 61/833,802).The transcranial Doppler probes will be incorporated in the pre-temporalregion and in the back of head (suboccipitally) into the helmet (see,e.g., FIGS. 3A, 5 & 6; paragraphs [0079], [0081] & [0082] of U.S. patentapplication Ser. No. 14/674,411, which are incorporated herein byreference). Transcranial Doppler mean blood flow velocity in majorcerebral arteries represents an indirect assessment of cerebralperfusion. Changes in cerebral blood flow can be inferred from changesin blood flow velocity; however, there are limitations in that aconstant vessel diameter and specific angle of insonation are assumed.Transcranial Doppler cannot measure perfusion abnormalities at themicrocirculatory level but large vessel territory perfusionabnormalities are relevant in stroke definition and determination forintervention. Operator expertise has limited transcranial Doppler but isobviated by the embodiments of the helmet and probe design.

Transcranial Color Coded Doppler (TCCD)

Similar to transcranial Doppler (TCD), transcranial color-coded Dopplercan be used to interrogate brain blood vessels for velocity and othermeasures. The difference with TCCD versus TCD is that in the former, thelarge and potentially medium sized vessels can actually be seen.Transcranial Doppler infers information on vessels based on theirlocation and depth and other parameter without direct visualization. ForTCCD, similar to carotid 2D and 3D Doppler, a picture of the vessel withpotential changes with or without stenosis or obstruction can be seen.In an exemplary embodiment, this may be employed as a primary oradditional measure for evaluating the large and potentially mediumvessels of the brain in stroke and in traumatic brain injury. In anexemplary embodiment, transcranial Doppler and transcranial colorDopplers can be deployed and used within the ambulance foridentification of large vessel stenosis, obstruction, as well as othermeasures and collateral brain circulation. In an exemplary embodiment,transcranial Doppler can be used to obtain other measures that reflecton brain intracranial pressure and vessel reactivity that can reflect onconditions of increased brain pressure, related to traumatic braininjury, brain swelling from many causes, or large stroke with brainswelling.

Phased Array

Phased Array Ultrasound enables the use of multiple transducers to bepulsed and readout independently. Having an array of such devicesenables beam steering, beam forming, and higher resolution imaging uponreturn of the reflected/scattered ultrasound. Due to the largerreceiving aperture, the beam can be electronically steered, and thenread back for that part of space interrogated by the smaller beam sizeenabled by the phased array beam-forming algorithms. Such devices areused in Medical Imaging and in many industrial applications. Typically,because of the much higher resolution afforded by MRI and CT scanningdevices, phase array ultrasound has not been used in the brain. However,when larger structures are imaged, such as major vasculature, and superbresolution is not desired, phased array ultrasound is adequate. Inparticular, phased array ultrasound can fit into a small box, of size10″×10″×3″, and be part of an ambulances or Emergency Department orother medical settings, equipment, as compared to the room-size MRI'sand CT scanning systems in common use. Phased array has been used tolook at brain blood flow velocities, similar to transcranial Doppler andthe probes could be placed in similar positions to transcranial Dopplerprobes.

Phased array probes may be used to replace transcranial Doppler probes.This can provide beam steering capacities that may increase theprocurement of brain vessel data. In an exemplary embodiment, inaddition to external use within the helmet, a phased array probe ortranscranial Doppler probe is combined with an optoacoustic orphotoacoustic probe to provide physiological vessel flow data,reflective of stenosis or obstruction, and oxygenation information oncontiguous brain tissue that is supplied by these vessels (See below).It should be appreciated that probes and transducers are synonymous andcan be used interchangeable in the application, and the probes of theinvention and could be carotid probes, transcranial probes, phased arrayor photoacoustic spectroscopy probes.

Photoacoustic Spectroscopy

Photoacoustic spectroscopy may be used as part of the evaluation ofoxygen and oxygenation externally in some embodiments. For example,probes for this would be added to the existing head parts of the helmet(not shown). Further, as part of this embodiment, a photoacoustic headwould be part of the transcranial Doppler and phased array multi-headprobes that would be used in intravascular evaluation in connection withcerebral angiography and interventional catheter based intra-arterialtherapy with clot buster or clot removal/stenting. Photoacousticspectroscopy is the measurement of the effect of absorbedelectromagnetic energy (particularly of light) on matter by means ofacoustic detection.

Photoacoustic imaging is based on the photoacoustic effect. Inphotoacoustic imaging, non-ionizing laser pulses are delivered intobiological tissues (when radio frequency pulses are used, the technologyis referred to as thermoacoustic imaging).

Some of the delivered energy will be absorbed and converted into heat,leading to transient thermoelastic expansion and thus wideband (e.g.,MHz) ultrasonic emission. The generated ultrasonic waves are thendetected by ultrasonic transducers. Computer systems of the inventionconvert these waves into images. It is known that optical absorption isclosely associated with physiological properties, such as hemoglobinconcentration and oxygen saturation.

Hemoglobin (Hb or Hgb) is the iron-containing oxygen-transportmetalloprotein in the red blood cells of most vertebrates. Hemoglobin inthe blood carries oxygen from the respiratory organs (lungs or gills) tothe rest of the body (i.e. the tissues) where it releases the oxygen toburn nutrients to provide energy to power the functions of the organism,and collects the resultant carbon dioxide to bring it back to therespiratory organs to be dispensed from the organism.

In general, hemoglobin can be saturated with oxygen molecules(oxyhemoglobin), or desaturated with oxygen molecules (deoxyhemoglobin).Oxyhemoglobin is formed during physiological respiration when oxygenbinds to the heme component of the protein hemoglobin in red bloodcells. This process occurs in the pulmonary capillaries adjacent to thealveoli of the lungs. The oxygen then travels through the blood streamto be dropped off at cells where it is utilized as a terminal electronacceptor in the production of ATP by the process of oxidativephosphorylation. It does not, however, help to counteract a decrease inblood pH. Ventilation, or breathing, may reverse this condition byremoval of carbon dioxide, thus causing a shift up in pH. In thisembodiment both as part of the external headset apparatus or the brainintra-arterial set of probes, photoacoustic spectroscopy would be usedto evaluate oxygenation, tissue efficacy, and as part of thedetermination of cerebral perfusion in combination with transcranialDoppler and phased array ultrasound and special fluorescentintravascular injection.

Vasculature and Perfusion Measurement

Perfusion may be used and is the process of delivery of blood to acapillary bed in the biological tissue. Vasculature and perfusionmeasurements in the brain perfusion (more correctly transit times) canbe estimated with contrast-enhanced computed tomography or MRangiography. To get a better representation of the blood flow in thebrain, a dye is injected into the patient to enhance visualization ofthe suspect area. Cerebral perfusion measurements are based onquantitative measures of cerebral blood flow, mean transit time (MTT),or time to peak flow (TTP and cerebral blood volume (CBV). In someembodiments, brain perfusion in specific regions of potential completedstroke and penumbral regions with still preserved function will involvetranscranial Doppler, phased array, photoacoustic spectroscopy, and ICNdye.

Tissue plasminogen activator (tPA) or clot buster is used in diseasesthat feature blood clots, such as stroke, pulmonary embolism, myocardialinfarction, in a medical treatment called thrombolysis. To be mosteffective in ischemic stroke, tPA must be administered as early aspossible after the onset of symptoms. Protocol guidelines require itsuse intravenously within the first three hours of the event (in somecases up to 4.5 hours), after which its detriments may outweigh itsbenefits. tPA can either be administered systemically or administeredthrough an arterial catheter directly to the site of occlusion in thecase of peripheral arterial thrombi and thrombi in the proximal deepveins of the leg. In some embodiments, the methods and devices includeintroducing iPA intravenously or intra-arterially into a patient afterassessing a patient for a stroke and evaluating for potential risk ofthis therapy in each specific patient situation.

A transcranial Doppler photoacoustic device can be used to transmit afirst energy to a region of interest at an internal site of a subject isdisclosed (the entire inside of the skull is illuminated, and producessound waves, proportional to the absorption of incident light). Themethod comprises the steps outputting optical excitation energy to saidregion of interest and heating said region, causing a transientthermoelastic expansion and producing a wideband ultrasonic emission. Aphased-array transducer system records the ultrasonic waves. Computersystems of the invention convert the waves into images. Because all ofthe transducers record simultaneously, the device can image the wholebrain area simultaneously.

By providing at least one, or a plurality of one or two dimensionaldetectors, the detectors receive wideband ultrasonic emission. An oxygenlevel is computed of said region of interest from said widebandultrasonic emission. Then, an array of ultrasound transducer elementsoutput a beam pattern from said array of ultrasound transducer elementsto insonate a region of interest at an internal site in a body, wherethe beam output pattern is sufficiently large to comprise a multi-beampattern. Multiple receiver elements insonate over a substantiallysimultaneous period by directing energy produced by said array ofultrasound transducer elements into said region of interest in saidbody, and adjusting an amplitude of energy output by said array oftransducers to cause the beam pattern output to have a generally flatupper pattern and nulls in a grating lobe region. This would beperformed by the user with the device and associated software.

Then a propagation time delay is introduced and the beam pattern outputfrom said array of ultrasound transducer elements, wherein thepropagation delay increases as a distance increases from a centraloutput area of said array of ultrasound transducer elements produces animage of said internal site. In addition, in software duringreconstruction, phase shifts can be selectively added to all of thesignals so that the reconstructed beam scans the whole brain cavity.

The photoacoustic technology deployed can use an unfocused detector toacquire the photoacoustic signals and the image is reconstructed byinversely solving the photoacoustic equations. Alternatively, thetranscranial Doppler photoacoustic device of this embodiment may use aspherically focused detector with 2D and 3D point-by-point scanning andwould require a reconstruction algorithm. Thermoelastic expansion of theblood vessel wall depends on the oxyhemoglobin/deoxyhemoglobin ratio. Inorder to obtain precise mapping of the area of interest, the Dopplerultrasound functionality of the device is utilized to provide an imageto the user.

Dye can be administered to a patient to visualize the brain vasculatureand a perfusion measurement can be made in various regions of the brainalong with the transcranial Doppler and the photoacoustic screening.

The photoacoustic technology deployed in this device uses an unfocuseddetector to acquire the photoacoustic signals and the image isreconstructed by inversely solving the photoacoustic equations.Alternatively, the transcranial Doppler photoacoustic device of thisembodiment may use a spherically focused detector with 2D and 3Dpoint-by-point scanning and would require a reconstruction algorithm,that operates in near real-time or after data acquisition is complete.Thermoelastic expansion of the blood vessel wall depends on theoxyhemoglobin/deoxyhemoglobin ratio. In order to obtain precise mappingof the area of interest, the Doppler ultrasound functionality of thedevise is utilized to provide an image to the user.

A laser-induced photoacoustic tomography (PAT) device (photoacousticspectroscopy) can also be used. PAT retains intrinsic optical contrastcharacteristics while taking advantage of the diffraction-limited highspatial resolution of ultrasound. This embodiment will also allow forimaging hyperoxia-and hypoxia-induced cerebral hemodynamic changes. ThePAT technology would show oxygenation levels and the phased arrayDoppler would present blood flow. This embodiment employs an algorithmof using velocities and blood distribution and oxygen level tosimultaneously to determine what is going on with neuronal respiration.This algorithm will determine the 12 types of strokes, as treatment isdifferent in a hemorrhagic stroke or an emboli-induced stroke, in thatthe blood distribution and velocities are far different in each type.

A microwave-based thermoaccoustic tomography (TAT) device can be used toimage deeply seated lesions and objects in biological tissues and thephased array Doppler or single receiver Doppler would present bloodflow. Because malignant tissue absorbs microwaves more strongly thanbenign tissue, cancers can be imaged with good spatial resolution andcontrast.

Phased array Doppler can be used to present blood flow using multiplewavelength photoacoustic measurements. Oxoborinic acid (Hb02) is thedominant absorbing compounds in biological tissues in the visiblespectral range, multiple wavelength photoacoustic measurements can beused to reveal the relative concentration of these two chromophores (thepart of a molecule responsible for its color). Thus, the relative totalconcentration of hemoglobin (HbT) and the hemoglobin oxygen saturation(s02) can be derived. Therefore, cerebral hemodynamic changes associatedwith brain function can be successfully detected with PAT. For example,under a hyperoxia status, the averaged s02 level, in the areas of imagedcortical venous vessels of brain is higher than that under the normoxiastatus.

Compounds in vascular walls can be excited by either phased arrayDoppler or the PAT. This would allow the analysis of the atheroma(plaque) on the linings of certain compounds on vasculature walls.

Ultrasonic transducers can be configured in different patterns to aid inthe reception of the photoacoustic signal, for example (but not limitedto), the transducers can be set up in an 8 by 8 array.

An algorithm deployed as software, firmware or hardware can be used toproduce data which can utilized to produce an image of the biologicaltissue. In an another embodiment, a tunable laser would be utilized forsubtraction and comparison differential imaging to see emboli, say inthe carotid artery, or subclavian artery, which are not underneath theskull or any additional areas of interest.

Different frequencies of light of the laser can be used to excitevascular wall, gaseous emboli, and fatty emboli, in superficial ordeeper vasculature, both in the skull or the general circulation, todetermine probability or likelihood of stroke or other vasculardisorder.

Transcranial Doppler can be used to detect emboli in the brain. Embolimay be gaseous or particulate. Examples of emboli include calcium, fat,platelets, red blood cells, clots, or other substances that travelthrough the bloodstream and lodges in a blood vessel. A stroke ortransient ischemic attacks (TIA) involve brain tissue damage thatresults from the obliteration of blood flow with reduced oxygen deliverythrough specific extracranial vessels, i.e. carotid arteries, cervicalvertebral arteries, or intracranial vessels, i.e. middle cerebralarteries, posterior cerebral arteries due to atherosclerotic vesselchange, emboli, or a combination of both. The size of these emboliccomponents is approximately 50 microns for particulate or solid emboliand 1-10 microns for gaseous emboli. Particulate emboli may have a moreimportant role in stroke or TIA causation, as compared to gas emboli;this underlies a need for detection and differentiation of particulateversus gas emboli.

Cerebral emboli may be associated with cardiac, aorta, neck andintracranial vessel disease, as well as coagulation disorders and neckand during diagnostic and surgical procedures on the heart and thecarotid arteries. Cerebral embolism can be a dynamic process episodic,persistent, symptomatic, asymptomatic, and may, but, not in all cases,predispose to stroke or TIA, influenced to some degree by compositionand size; the latter embolic stroke, which is influenced by the vesseland its diameter to which the embolus goes.

Raman Spectroscopy

In one or more exemplary embodiments, an application of infrared light,modulated at 200 kHz to 30 MHz frequencies can be used to excitecontrast agents or certain molecules in the brain and release ultrasoundwaves. This can be applied behind the skull, in blood cells, in tissue,and in serum or plasma. This application combines photoacoustic andultrasound methodology. Raman infrared wavelengths of approximately 10microns are used to make a photo-acoustic image. Raman methodology isable to distinguish hemoglobin with oxygen from hemoglobin withoutoxygen, as well as specific proteins, mRNA molecules, microRNAmolecules, and look at specific DNAs. Raman spectroscopy can also definesmall point mutations in a DNA molecule in patients that may differentfrom normal as well as variants called SNPs or restriction lengthpolymorphisms that may be involved in disease pathogenesis. Raman cantherefore be used for genetic profiling or to define abnormalities thatmay cause or underlay specific diseases. In traumatic brain injury andstroke, specific molecules may rise or change, in specific types orsubsets of these disorders, including concussion and large vesselobstruction strokes. Stroke may also be associated with certain geneticabnormalities or SNPs that warrant detection for therapy preventatively.In one or more exemplary embodiments, Raman Spectroscopy in thepre-hospital and non-emergent situations can be employed.

Other measurement techniques have been used in non-urgent situations andcan be used in real-time in traumatic brain injury and concussion forqualitative and quantitative molecular biomarkers and potentialdiagnosis of traumatic brain injury, concussion, and other braindisorders. These measurements techniques including, for example (but notlimited to), Western blot technology, genomic, proteomic, metabolomic,lipidomic, and other methodologies. Similar methodologies and moleculeshave been identified in specific stroke types using proteomic,metabolomic, molecular biological/genetic tools. In traumatic braininjury, concussion, stroke, other brain disorders, and non-brain medicaldisorders, these biomarkers can be identified in blood, blood cells,serum, plasma, cerebrospinal fluid, urine, and brain and other tissues.In an exemplary embodiment, these tools will be combined with RamanSpectroscopy for point-of-care diagnostics with other point-of-caremolecular analysis devices for diagnosis of stroke, traumatic braininjury, concussion, and other neurological and medical disorders.

Traumatic Brain Injury and Concussion

At least 1.7 M individuals per year may sustain traumatic brain injuryand concussion and 20% of military personnel may sustain traumatic braininjury, including but not limited to blast injury, concussion and/ormajor traumatic brain injury. Early on, this may involve alteration ofconsciousness, seizures, weakness of both or one side of the body,inability to speak or understand speech and other neurologicaldysfunction and death. Sequelae of traumatic brain injury include severeneurological disability, seizures, learning disability, mood disorder,suicide, post-traumatic stress disorder, other psychiatric disorders,memory disorder, cognitive disorders, and dementia. The early clinicaldisorders and abnormalities in traumatic brain injury can be predicatedon neuronal dysfunction and death, brain swelling, brain immunologicalresponses, large neck or brain spasm of vessels with narrowing ofvessels and reduced blood flow, large neck or blood vessel tearing(dissection) large or small brain bleeds (hemorrhage) within the brainsubstance, other bleeding including bleeds into spaces that surround thebrain, i.e., subarachnoid bleeds, epidural and subdural bleeds(hematoma). Early diagnosis and early appropriate treatment of traumaticbrain injury, similar to stroke, is essential to delimit morbidity andmortality and to prevent neurological and psychiatric sequelae. In theacute phase of traumatic brain injury (TBI), neurological and otherclinical examination, evaluation for brain and neck blood vesselobstruction or tearing, i.e., dissection, evaluation of shifts in thebrain contents due to blood or swelling (edema), and vessel spasms, canbe evaluated in real time with telemedicine neurological and otherclinical examination and including, but not limited to, carotid Dopplerand transcranial Doppler, and by specific traumatic brain injurymolecular measures can be done. The carotid Doppler can detect vesselobstruction and vessel tearing. The transcranial Doppler can detectbrain vessel obstruction, emboli, vessel spasm, and abnormalities invessel reactivity. The latter can be an earlier and specific detectorfor concussion. In an exemplary embodiment, these measures can be doneand also an expansion of the device has the capacity to detect shift inbrain content due to edema or hemorrhage. In an exemplary embodiment,neurological and other clinical examination, transcranial Doppler,and/or carotid Doppler can be performed to allow for early diagnosis,early treatment, similar to stroke. In an exemplary embodiment, thisdata can be interfaced with other devices in this disclosure, including,for example (but not limited to), the devices discussed in paragraph[00261] below.

Inclusions and Exclusions for Stroke Acute Treatment.

Well-established national and international criteria are recommendedand/or required screened, in acute stroke, where there is considerationfor clot buster, tPA or endovascular clot removal. These include astandard questionnaire that determines the time last known normal. tPAis generally not warranted if the patient had stroke symptoms or waslast known well at 3 hours and potentially up to 4.5 hours. Forendovascular intervention, 6-8 hours from time of last known well, butthis can be longer, based on local criteria (up to 12-16 hours) is used.If these times are exceeded, then these types of therapies, e.g., clotbuster, endovascular clot removal, are not clinically warranted.Exclusions include but are not limited to elevated clotting profiles,use of anticoagulants, prior recent major surgery or head injury.Elevated blood pressure of 180 systolic or above, if not corrected, isan exclusion for clot buster, tPA. Relative exclusions may be diabetesor age over 80 years. Each case is different and warrants expertneurological and radiological evaluation for decision making. Given theimportance of time for potential reversal of brain injury orpreservation of brain function in stroke, any means that will reducetime to diagnosis and treatment is useful. In an exemplary embodiment,this is clinical information that will be collected and be part of theclinical notes generated by neurologists and radiologists through theoperations center as part of the telemedicine system. Blood drawingwithin the ambulance or moving vehicle, may limit one step that requirestime, at the receiving hospital. Blood analysis for glucose, fullchemistry panel, blood count, blood coagulation profiles, and otherstandard blood are part of the standard needed studies. Other bodilyfluids may also be analyzed. The actual determination of the bloodresults within an ambulance with ambulance blood laboratories has beenestablished and promotes earlier diagnosis, exclusions, and treatmentdecisions. In an exemplary embodiment, when these are available, theresults and data form this blood analysis can be reviewed andtransmitted with the telemedicine system disclosed herein as part ofearlier diagnosis and a change in the process and logistics for strokecare.

Establishment of Brain Hemorrhage in Stroke and Traumatic Brain Injury.

13-15% of strokes are hemorrhagic. Hemorrhage is an absolute exclusionfor clot buster, tPA. Endovascular clot retrieval is not a part of thetreatment pathway for non-hemorrhagic stroke. However, theidentification of hemorrhage has required a CT scan or less likely, aMRI scan of brain. In some cases, a spinal tap is also required to rulein or rule out a bleed. A device that could detect blood by ultrasoundor other measures would be useful, particularly in the ambulance orother moving vehicle, to determine appropriate treatment for thereceiving hospital. In an exemplary embodiment, the telemedicine systemcan interact or include such a device or can interface to an existingdevice. An ambulance CT scan can be definitive to determine brainhemorrhage. As such, a small number of ambulances with head CT scannershave recently been deployed. These are limited by expense and geography,requiring proximity to a major tertiary medical center. However, whenutilized, the head CT scanners can identify a brain bleed and, whencombined with a neurological examination and general blood profiles withclotting measurements, can lead to the administration of a clot busterin the ambulance, with earlier stroke treatment, prehospitally. However,these ambulances are limited by the connectivity and quality anddelivery of the imaging data of the neurological examination and imagingexamination. In an exemplary embodiment, the telemedicine system canoperate and interact with ambulance CT systems to allow for improvementor resolution of the connectivity, quality of service, and delivery ofimaging data. Additionally, neurosurgery notification and involvementare essential for preventing, diagnosing and/or treating hemorrhagicstroke. In a further exemplary embodiment, the telemedicine systemprovides for real time communication with and determination by a medicalpersonnel (such as a neurosurgeon) regarding a patient. With thetelemedicine system, the medical personnel can communicate and determinein real time appropriate hospital delivery, hospital preparation and/orneurosurgical direct involvement based on real time transmitted blooddata.

In an exemplary embodiment, the telemedicine system can also be used tocollect and transmit direct video and audio information and data fromone or more devices that reflect on brain function and other organsystems, including, but not limited to, brain wave orElectroencephalogram (EEG) data using one or more EEG devices, forexample (but not limited to), Brainscope's Ahead™ 300, the ElMindAdevice and/or other EEG devices for evaluation for seizures, traumaticbrain injury, concussion, and other brain disorders; one or more devicesthat measure brain blood flow, for example (but not limited to), C-FLOW™(Ornim), or brain oxygenation; one or more brain pressure measurementdevices, for example (but not limited to), Cerepress™ (Third EyeDiagnostics); one or more potential brain hemorrhage detection devices,for example (but not limited to), INFRASCANNER; one or more ultrasounddevices that can look at the thickness or anatomy of the optic nervesfor brain pressure; one or more ultrasound devices that evaluate heartand other organs, eye movement analysis devices for TBI and otherneurological disorders; one or more telemedicine otoscopes or viewingdevices for ear disease or signs of TBI with bleeding in the ear as wellas pupillary response, for example (but not limited to), Fireflywireless digital video otoscope; one or more telemedicineophthalmoscopes that look externally and internally into the eye and itsoptic disc and retina; one or more devices that use telemedicine toauscultate or listen to the heart or lungs, for example (but not limitedto), Thinklabs digital stethoscope; one or more blood pressuremeasurement devices that accurately measure blood pressure withapplication to high and low blood pressure disorders; an intracranialpressure measurement device;, brain hemorrhage diagnostic device,non-brain diagnostic device, blood diagnostic test device; bodily fluiddiagnostic test device, or a combination thereof. The telemedicinesystem can also be used in combination with machine learning and otherartificial intelligence to compliment and augment the directtelemedicine and device analysis for stroke blood vessel measurementsand other physiological measurements.

In an exemplary embodiment, the telemedicine system is a system ofconnectivity and quality of service that can be applied to non-medicalenvironments in rural, urban, extreme rural, maritime, and/or aviationenvironments for observing and evaluating equipment and for transmittingdata from equipment for efficacy and malfunction assessment.

The aforementioned description of the specific aspects will so fullyreveal the general nature of the disclosure that others can, by applyingknowledge within the skill of the art, readily modify and/or adapt forvarious applications such specific aspects, without undueexperimentation, and without departing from the general concept of thepresent disclosure. Therefore, such adaptations and modifications areintended to be within the meaning and range of equivalents of thedisclosed aspects, based on the teaching and guidance presented herein.It is to be understood that the phraseology or terminology herein is forthe purpose of description and not of limitation, such that theterminology or phraseology of the present specification is to beinterpreted by the skilled artisan in light of the teachings andguidance.

References in the specification to “one aspect,” “an aspect,” “anexemplary aspect,” etc., indicate that the aspect described may includea particular feature, structure, or characteristic, but every aspect maynot necessarily include the particular feature, structure, orcharacteristic. Moreover, such phrases are not necessarily referring tothe same aspect. Further, when a particular feature, structure, orcharacteristic is described in connection with an aspect, it issubmitted that it is within the knowledge of one skilled in the art toaffect such feature, structure, or characteristic in connection withother aspects whether or not explicitly described.

The exemplary aspects described herein are provided for illustrativepurposes, and are not limiting. Other exemplary aspects are possible,and modifications may be made to the exemplary aspects. Therefore, thespecification is not meant to limit the disclosure. Rather, the scope ofthe disclosure is defined only in accordance with the following claimsand their equivalents.

Aspects may be implemented in hardware (e.g., circuits), firmware,software, or any combination thereof. Aspects may also be implemented asinstructions stored on a machine-readable medium, which may be read andexecuted by one or more processors. A machine-readable medium mayinclude any mechanism for storing or transmitting information in a formreadable by a machine (e.g., a computing device). For example, amachine-readable medium may include read only memory (ROM); randomaccess memory (RAM); magnetic disk storage media; optical storage media;flash memory devices; electrical, optical, acoustical or other forms ofpropagated signals (e.g., carrier waves, infrared signals, digitalsignals, etc.), and others. Further, firmware, software, routines,instructions may be described herein as performing certain actions.However, it should be appreciated that such descriptions are merely forconvenience and that such actions in fact results from computingdevices, processors, controllers, or other devices executing thefirmware, software, routines, instructions, etc. Further, any of theimplementation variations may be carried out by a general purposecomputer.

For the purposes of this discussion, the term “processor circuitry”shall be understood to be circuit(s), processor(s), logic, or acombination thereof. For example, a circuit can include an analogcircuit, a digital circuit, state machine logic, other structuralelectronic hardware, or a combination thereof. A processor can include amicroprocessor, a digital signal processor (DSP), or other hardwareprocessor. The processor can be “hard-coded” with instructions toperform corresponding function(s) according to aspects described herein.Alternatively, the processor can access an internal and/or externalmemory to retrieve instructions stored in the memory, which whenexecuted by the processor, perform the corresponding function(s)associated with the processor, and/or one or more functions and/oroperations related to the operation of a component having the processorincluded therein.

In one or more of the exemplary aspects described herein, processorcircuitry can include memory that stores data and/or instructions. Thememory can be any well-known volatile and/or non-volatile memory,including, for example, read-only memory (ROM), random access memory(RAM), flash memory, a magnetic storage media, an optical disc, erasableprogrammable read only memory (EPROM), and programmable read only memory(PROM). The memory can be non-removable, removable, or a combination ofboth.

As will be apparent to a person of ordinary skill in the art based onthe teachings herein, the communication protocols of the exemplaryembodiments are not limited, and can include, for example, Long-TermEvolution (LTE), and can be applied to other cellular communicationstandards, including (but not limited to) Evolved High-Speed PacketAccess (HSPA+), Wideband Code Division Multiple Access (W-CDMA),CDMA2000, Time Division-Synchronous Code Division Multiple Access(TD-SCDMA), Global System for Mobile Communications (GSM), GeneralPacket Radio Service (GPRS), Enhanced Data Rates for GSM Evolution(EDGE), and Worldwide Interoperability for Microwave Access (WiMAX)(Institute of Electrical and Electronics Engineers (IEEE) 802.16) toprovide some examples. Further, exemplary aspects are not limited tocellular communication networks and can be used or implemented in otherkinds of wireless communication access networks, including (but notlimited to) one or more IEEE 802.11 protocols, Bluetooth, Near-fieldCommunication (NFC) (ISO/IEC 18092), ZigBee (IEEE 802.15.4), and/orRadio-frequency identification (RFID), to provide some examples.Further, exemplary aspects are not limited to the above wirelessnetworks and can be used or implemented in one or more wired networksusing one or more well-known wired specifications and/or protocols.

What is claimed is:
 1. A telemedicine system operable to communicatewith a remote operations center, comprising: a transceiver configured totransmit or receive one or more communications via an antenna havingfirst and second di-pole antenna elements, the first di-pole antennaelement being vertically polarized and the second di-pole antennaelement being horizontally polarized; and a controller connected to thetransceiver and configured to: establish, using the transceiver, atelemedicine session with the operations center using a TransportMorphing Protocol (TMP), the TMP being an acknowledgement-based userdatagram protocol; and mask one or more transient network degradationsto increase resiliency of the telemedicine session.
 2. The telemedicinesystem of claim 1, wherein the controller is configured to (a) adjustdata send rate of the telemedicine session to reduce packet loss andreduce the resending of packets of the telemedicine session and (b)switch between cellular communication and satellite communication upondetecting a transient network loss.
 3. The telemedicine system of claim2, wherein the controller is configured to encrypt communications of thetelemedicine session such that the telemedicine session is a securetelemedicine session; the controller being connected to a router, therouter being connected to a cellular modem and two different kinds ofsatellite modems.
 4. The telemedicine system of claim 3, wherein the twodifferent kinds of satellite modems include a first modem configured totransmit data over a Ku or Ka band antenna and a second modem configuredto transmit data over an L-Band antenna.
 5. A vehicle comprising thetelemedicine system of claim 4, a plurality of wheels, and a motorconfigured to drive the plurality of wheels.
 6. The telemedicine systemof claim 1, further comprising a router connected to the transceiver,the router being configured to route communications between thecontroller and the transceiver, and wherein the controller is configuredto controller the router to dynamically switch between the two or morewireless communication protocols.
 7. The telemedicine system of claim 1,further comprising a satellite transceiver configured to transmit orreceive one or more satellite communications to/from one or moreorbiting satellites.
 8. The telemedicine system of claim 7, wherein thecontroller is configured to control the telemedicine system todynamically switch communications of the telemedicine session betweenthe transceiver and the satellite transceiver.
 9. The telemedicinesystem of claim 8, further comprising a router connected to thetransceiver and the satellite transceiver, wherein the controller isconfigured to control the router to dynamically switch thecommunications of the telemedicine session between the transceiver andthe satellite transceiver.
 10. The telemedicine system of claim 1,wherein the first di-pole antenna element includes first and secondvertically-arranged antenna radiators, the first vertically-arrangedantenna radiator being arranged orthogonal to the secondvertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other.
 11. The telemedicine system ofclaim 1, wherein the second di-pole antenna element includes first andsecond horizontally-arranged antenna radiators, the first and the secondhorizontally-arranged antenna radiators being arranged in a samehorizontal plane.
 12. The telemedicine system of claim 1, wherein: thefirst di-pole antenna element includes first and secondvertically-arranged antenna radiators, the first vertically-arrangedantenna radiator being arranged orthogonal to the secondvertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other; and the second di-pole antennaelement includes first and second horizontally-arranged antennaradiators, the first and the second horizontally-arranged antennaradiators being arranged in a same horizontal plane.
 13. Thetelemedicine system of claim 1, wherein the first and second di-poleantenna elements are enclosed in a single radome.
 14. The telemedicinesystem of claim 1, further comprising: one or more medical imagingmodalities configured to generate one or more medical images of apatient, wherein controller is configured to transmit the one or moremedical images to the operations center using the transceiver; asatellite transceiver comprising: a VSAT modem connected to a flat panelphased array satellite terminal comprising at least one antennaconfigured to communicate over Ku or Ka bands, an L-Band satellite modemconnected to an L-band satellite antenna, and a router connected to boththe VSAT modem and the L-Band satellite modem; the controller beingconfigured to monitor signal strength of the VSAT modem and the L-Bandmodem and to cause the router to dynamically switch between the modemsbased on the monitored signal strengths.
 15. A telemedicine systemoperable to communicate with a remote operations center and one or moremedical facilities, comprising: a transceiver configured to transmit orreceive one or more communications using the two or more wirelesscommunication protocols via an antenna having first and second di-poleantenna elements, the first di-pole antenna element being verticallypolarized and the second di-pole antenna element being horizontallypolarized; a satellite transceiver configured to transmit or receive oneor more satellite communications to/from one or more orbitingsatellites; a router connected to the transceiver and the satellitetransceiver, the router being configured to route communications to andfrom the transceiver and the satellite transceiver and to dynamicallyswitch between the two or more wireless communication protocols; acontroller connected to the transceiver and the satellite transceivervia the router, the controller being configured to: establish, using atleast one of the transceiver and the satellite transceiver, atelemedicine session with the operations center and the one or moremedical facilities using a Transport Morphing Protocol (TMP), the TMPbeing an acknowledgement-based user datagram protocol; and mask one ormore transient network degradations to increase resiliency of thetelemedicine session; and at least one or more medical measurementdevices operably connected to the controller and configured to providemedical information of a patient to the controller for use during thetelemedicine session.
 16. The telemedicine system of claim 15, whereinthe controller is configured to encrypt communications of thetelemedicine session such that the telemedicine session is a securetelemedicine session.
 17. The telemedicine system of claim 15, whereinthe first di-pole antenna element includes first and secondvertically-arranged antenna radiators, the first vertically-arrangedantenna radiator being arranged orthogonal to the secondvertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other.
 18. The telemedicine system ofclaim 15, wherein the second di-pole antenna element includes first andsecond horizontally-arranged antenna radiators, the first and the secondhorizontally-arranged antenna radiators being arranged in a samehorizontal plane.
 19. The telemedicine system of claim 15, wherein: thefirst di-pole antenna element includes first and secondvertically-arranged antenna radiators, the first vertically-arrangedantenna radiator being arranged orthogonal to the secondvertically-arranged antenna radiator, wherein the firstvertically-arranged antenna radiator and the second vertically-arrangedantenna radiator intersect each other; and the second di-pole antennaelement includes first and second horizontally-arranged antennaradiators, the first and the second horizontally-arranged antennaradiators being arranged in a same horizontal plane.
 20. Thetelemedicine system of claim 15, wherein the collected and transmittedaudio, video or medical information is reviewed in real-time by at leastone physician to diagnosis and/or treat the patient suffering fromstroke, a traumatic brain injury, a neurological disorder, an organsystem medical disorder, or a combination thereof.